Case Scenario

I work in a group practice. For the most part, the physicians in our group have similar prescribing practices. However, one of my colleagues prescribes narcotics far more often than the rest of us. Whereas most of us keep a tight rein on controlled substances and have a very small number of patients who chronically require such medications, this colleague has developed a sizable group of patients who rely on narcotic medications to treat chronic pain. He feels that it's his duty to relieve his patients' suffering and is willing to use controlled substances to achieve this. We have passed around some sample “narcotic contracts” for patients to sign, but he feels that asking patients to sign is demeaning because it insinuates that anyone with chronic pain may actually be a drug seeker.

We all agree that our colleague is a fine, compassionate physician. His general care of patients is excellent. In regard to the use of narcotics, his practice patterns differ from those of the other physicians in the group. When I cover for this colleague, I review his patients' charts and find myself thinking that I would have handled the situation differently. In these cases, I'm uncomfortable refilling his patients' pain medications because I wouldn't have prescribed narcotics in the first place.

Although we've mentioned some of these differences to him, we've never really sat down with him to hash it out. We're not sure he's out of line. Even if he were, what should we say to him? And when we're covering for him, what should we tell his patients who want narcotics?

Commentary

Physicians regularly face the ethical dilemma of determining whether the prescribing habits of a colleague are appropriate, and must then decide how to deal with that person. Such situations can engender hostility and resentment among colleagues and are rarely easily handled.

Appropriate prescribing is best defined as providing reasonable dosages of effective medications to the correct patients in a manner that is carefully monitored and that provides improvement in the patient's functioning and daily life. If the colleague is truly misprescribing, it is usually because of one of four reasons: he is dated, duped, disabled or dishonest. In other words, he may not have kept up with his education on pain management, he may be easy to manipulate, he may be chemically dependent himself or he is making a profit by misprescribing. Parenthetically, the illicit sale of prescription medication is a booming and profitable business; for example, the sale of hydromorphone (Dilaudid) typically brings in about $40 per pill. However, most physicians who misprescribe fall into the first two categories.

To determine whether a physician is prescribing appropriately, the most important question to ask is whether his patients are actually improving with the medical intervention.^1,2 One should also consider the following questions: Has the level of pain improved? Is the patient working again? Is the dosage of medication reasonably stable? Is there overt evidence of abuse or intoxication? Is this physician the only one prescribing these medications? Is the physician controlling the medication process or is the patient? Does the physician feel manipulated? One should look for early refills, numerous excuses and evidence of drug abuse and intoxication (Table 1).

Fortunately, the Federation of State Medical Boards recently adopted guidelines that clearly provide a framework for pain management.³ For the first time, physicians have an excellent, defensible set of guidelines within which to operate. While assessing the colleague's practice, one could apply the elements of these guidelines, which include the following: (1) thorough evaluation of the patient, (2) development of a treatment plan, (3) informed consent and agreement for treatment, (4) periodic review, (5) consultation, (6) adequate medical records and (7) compliance with controlled substance laws and regulations. In Kansas, the State Board of Healing Arts has determined that if these standards are followed, the board will support those physicians if questioned by other regulatory or enforcement agencies.⁴

Physicians have a responsibility to relieve the suffering of their patients, but this must be done within certain boundaries. Evidence suggests that adequate pain management reduces morbidity and the likelihood of abuse. A pharmacologic ladder (Table 2) of prescribing may be useful and further justifies the use of stronger narcotics when less potent medication has failed. The ladder is not meant to be an exclusive approach, and physicians may find that using some of the medications concurrently is beneficial.

If the patient's pain is severe enough to justify the use of narcotic medication, I prefer starting with small amounts and then carefully increasing the dosage as necessary. I never provide the patient with more than a single month of narcotic medication, and I require that the prescription always be filled only by me at the same pharmacy. If it is clear that the occasional narcotic medication is not adequately relieving the pain, I will ultimately choose a long-acting agent. Sustained-release morphine derivatives lend themselves nicely to the treatment of chronic pain. With all narcotics, the physician must be vigilant of overdose, abuse or diversion by the patient. Periodically checking pharmacy records to rule out the patient who may be filling prescriptions from multiple physicians is useful. Drug screening also helps to determine concurrent use of street drugs. Answering services can be useful allies in identifying drug-abusing patients who “doctor shop” and repeatedly call for drugs after hours.

Dosages of narcotic medications can become high enough in the legitimate patient that the physician feels uncomfortable providing them. In that circumstance, validating one's choices with consultants is useful. Consulting a pain specialist is particularly helpful. The legitimate patient usually plateaus in his or her medication dosage, and medication requirements will often wax and wane. It is useful to periodically taper medication if the level of pain has been stable for an extended period of time.

If the evidence suggests misprescribing, it is important to carefully assemble the evidence that validates or rules out the allegation, and then to share it with the other members, a professional affairs committee or a medical director.

The changes and expectations in prescribing habits that are required of the physician colleague should be quite concrete when they are presented. Prescribing needs to be monitored for an appropriate period of time, such as one year. The consequences of failing to adhere to expectations must be clearly spelled out. These may even include such actions as termination of employment or reporting to disciplinary agencies as a last resort. Condoning such misprescribing has a potential medicolegal impact on physician partners in a group, but making hasty or unfounded accusations can risk legal retribution.