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Renewing Opioid Prescriptions Over the Phone

Ask the Expert: Should You Renew Over the Phone?
Q: A patient with bona fide, severe spine disease is taking methadone with hydrocodone/acetaminophen (APAP) for breakthrough pain. The patient has missed three consecutive monthly appointments. He calls his physician’s office for another monthly refill of his medications. His pain doctor tells him he just can’t keep refilling controlled drugs without a face-to-face visit. The patient starts sobbing and says he just can’t afford to see the doctor and has no insurance. What should the doctor do?

A: “I can’t afford the visit.” “I can’t afford the urine drug screen.” “I can’t afford the x-ray you ordered for me.” These stories are common, and the patients are often legitimate. Unfortunately, when it comes to opioid prescribing, one of the most common reasons that healthcare providers get into problems with regulatory agencies is that—in the prescriber’s reluctance to deny pain relief to an apparently legitimate patient—he or she ignores the usual guidelines for opioid prescribing. The result could well be that the physician risks finding him or herself not permitted to prescribe opioids even to compliant patients as a result of some legal or medical licensing board action. I believe that the prescriber cannot afford to risk his or her ability to help many people by continuing to prescribe for one specific patient. Sometimes the patient may be persuaded to change his or her financial priorities (ie, stop buying cigarettes and use the savings to pay for the doctor visit or the x-ray); or perhaps the patient may have to borrow the money. Another choice is for the doctor to lower his or her fee for the next visit. Regardless, I believe the physician should not continue to prescribe opioids for this patient unless the patient is seen face to face. As to how frequently that needs to be depends on how stable the patient’s condition is and the physician’s comfort level. For my established stable patients, I usually see them every two months, and rarely every three months if they live out of town or have significant physical difficulties getting to the office. Finally, I wonder whether the doctor in this case has explored how compliant the patient has been with nonopioid treatments that do not cost money on a regular basis, such as home exercises to strengthen his back muscles.

Jennifer P. Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management
Tucson, AZ

A: Renewing prescriptions without an in-person visit between the patient and the prescribing practitioner can present significant legal challenges—especially when a patient goes for months without an in-office visit. Dr. Schneider raises solid reasons for setting clear boundaries regarding patient follow-up visits—establish these early and reinforce them as necessary throughout the treatment relationship. Fortunately, there are ways to “see” a patient when travel becomes either a financial or physical challenge or both. Telemedicine laws in many states contemplate the use of new technology to enable practitioners and patients to connect, but only after initial in-person contact and the establishment of a solid treatment plan and monitoring expectations. Although I am not advocating that telemedicine be used in the case presented, it may well be a consideration for some patients. Patients who consistently fail to show up for scheduled appointments present a serious obstacle to the trust and required demonstration of compliance with clinical and legal standards necessary for the legitimate prescribing of controlled medications. The practitioner should require the patient to present for an in-office visit, re-evaluate the patient’s situation, and modify the treatment plan to ensure the appropriate degree of medical supervision over this patient. A failure to do so may be viewed as “reckless disregard” for the conduct boundaries of a prudent physician.

Jennifer Bolen, JD
J. Bolen Group, LLC
Knoxville, TN

Last updated on: November 7, 2011
First published on: October 1, 2011