Best Practices For High-dose Opioid Prescribing
A 55-year-old construction worker was referred because his primary care physician didn’t feel comfortable prescribing 900 oxycodone tablets per month, at 30 mg each. The daily dosage was 30 tablets per day (900 mg), which the patient had taken for more than 5 years. His pain was due to lumbar spine degeneration. The patient does not have health insurance and has been unable to obtain x-rays, urine tests, endocrine tests, or genetic tests. His wife and he concur that he must work to take care of his family, and he can’t do so without his pain medications. The family can afford to pay for his oxycodone and a doctor’s office visit, but not much else. The wife claims he doesn’t abuse or divert any of his medications, and there have been no third-party reports of diversion, abuse, or sedation. What should the physician recommend?
Answer: As I understand it, a physician is seeing for the first time a patient who has been taking 900 mg/day of oxycodone for 5 years without having obtained any evaluation or having had a comprehensive treatment plan. We assume he is able to do physical labor as a construction worker. He can’t afford to get x-rays or urine tests, but spends probably $500 to $800 per month on medications plus doctor visits of unknown frequency. It’s unclear whether the patient is now being seen for a one-time consultation or to take over the prescribing and whether the writer is another primary care doctor or a specialist.
Regardless, the standard of care for prescribing opioids for chronic pain requires an initial assessment that includes: 1) requesting old medical records; 2) inquiring about the patient’s medical history including prior diagnostic workups and treatments for the presenting complaint, addiction history (including tobacco and alcohol use), and current level of functioning and level of pain; 3) performing a physical examination and ordering any diagnostic tests (eg, spine x-rays) that are relevant for treatment decisions; and 4) obtaining a urine drug test to confirm that the patient is taking the opioid he says he is and is not using illicit substances or other controlled drugs not on his medication list.
The results will determine the physician’s treatment plan. For example, let’s say the patient is getting good pain relief on this high dose of oxycodone, and is functioning well. Old records confirm that lower doses didn’t provide adequate pain relief and that this regimen was chosen because the patient could not afford sustained-release formulations (which are preferred for chronic pain management). If the x-rays support his stated diagnosis of lumbar spine degenerative disc disease and the urine drug test is negative (that is, it shows only the expected results—in this case, oxycodone and oxymorphone), the treatment plan might include an opioid, an anticonvulsant if there is also radicular pain, a physical therapy visit to craft a home exercise program, etc. The ongoing opioid costs can be significantly diminished by transitioning the patient to methadone, which is far less expensive than oxycodone. That would free up funds to pay for the necessary imaging studies and occasional urine drug tests. If the patient is a smoker, quitting smoking would free up additional funds.
If the patient declines to obtain x-rays, urine drug screens, and any consultation the physician deems necessary, then the physician has little choice but to decline to prescribe opioids for that patient. It’s not good medical care, and it’s too risky for the physician to cut corners and agree to prescribe without the necessary diagnostic evaluation or follow-up visits and compliance monitoring. This is always true, but particularly so when the monthly prescription consists of a very large number of pills of a short-acting opioid—a less-than-ideal situation, which often serves as a red flag for regulatory scrutiny. It can result in the physician losing his or her license and being unable to prescribe for any other patients.
Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management
Answer: I think it is really important to point out the fact that state licensing board rules set only minimum standards and do not necessarily represent best practices. This is an important concept when considering whether to prescribe to the above patient.
Dr. Schneider’s response contains a blend of both minimum standards (care standard) and best practices: minimum standards to do the history, physical examination, look at risk issues, construct a treatment plan that is designed to benefit the patient, and order appropriate diagnostic evaluations (or review those done in the past) to document available objective evidence of the pain pathology (where possible). Best practices include prescription monitoring programs, urine drug testing, referrals, consideration of alternative administration routes for medications, non-drug therapies, etc.
Licensing boards also expect the prescriber to take reasonable measures in order to prevent abuse and diversion. Such expectations include evaluating the type of opioid product and number of dosage units, and considering alternative routes of drug administration, safe storage, and safe disposal issues to possibly cut down on the medical and general safety risks associated with opioid therapy—high dose or not.
Dr. Schneider’s reference to best practices may relate to steps that are not specifically mentioned in licensing board rules, but instead arise out of the clinical literature and continuing medical education courses in pain management. While it may be virtually impossible for all physicians to achieve all best practices given the status of our current health care system, community, and patient resources, the scenario demands that the prescriber demonstrate a good faith effort to invoke certain best practices or risk loss of license or worse.
Courtroom attorneys need “ammunition” to fight accusers. The ammunition comes from the prescriber-client testimony and directly out of the patient record (evidence of the protocols, routines in place). The best ammunition is a result of demonstrable performance at more than the “minimum standards” level and evidence of a good faith effort to incorporate into the daily practice routine as many “best practices” as possible (those that have data and those that make common sense). When an attorney can show the client’s pain management treatment involved a fundamental and progressive application of not only the minimum standards but also incorporated best practices, the attorney can then mitigate against the loss of license, registration, etc.