OPMC, the Office of Professional Medical Conduct, is the enforcement arm of the New York State Department of Health, and it is closely evaluating physicians who are treating long term pain management patients. While any licensed physician can prescribe narcotics, OPMC will look very carefully at the treatment of a physician who is not a qualified pain management specialist. So, if you are an internist or other specialist and are treating patients with chronic pain, your records must be exceedingly accurate and must demonstrate that you have ordered the correct tests, have had the patient go to the proper specialists, have pinpointed exactly where the person’s pain is and what is the likely cause. Can the pain be successfully treated with physical therapy, or injections, or acupuncture or massage therapy or, as a last resort, surgery? Obviously, before you can answer those questions you have to send the patient to other physicians/therapists to determine if there is a way to make the patient reasonably comfortable from a pain point of view. The idea is that OPMC wants to have pain dealt with, if possible, in a way that does not involve the constant re-ordering of more and more narcotics.
So, what should your initial visit office record look like? For starters, OPMC wants to see a list of every drug the patient is taking along with the strength of the medication and the frequency of use. Then the name of the previous physician should be in the chart and you should move immediately to obtain that doctor’s office notes. Is the patient coming to see you because the previous physician would not give any more medication to a patient who is drug addicted? Has the patient ever been hospitalized for a drug overdose? The patient probably will not tell you the truth, but this is something you have to know before you start ordering narcotics. The last thing you want to deal is the death of your patient from an overdose, either by accident or by suicide. If your records are not completely up to date and complete, showing you took every precaution to prevent the patient’s death, then you may well be held responsible both by OPMC and in court via a wrongful death lawsuit.
Your records must also contain toxicology studies looking for drugs in the patient’s system. What if you are prescribing narcotics but none show up in the patient’s urine? That is a pretty good hint that the patient is not taking the drugs. So, does the patient not have any pain? If so, why are you ordering drugs? Is the patient selling the drugs? Probably, and that is a directive to you to stop ordering drugs for this patient. Of course, to make these decisions you have to actually read the lab reports from the top to the bottom, something, I can assure you, not every doctor does.
What to do if the toxicology reports show that the patient is also taking marijuana and/or cocaine? Again, you have to read the reports to know what is actually going on. Your notes had better reflect the fact that you are aware of the street drug issue and that you had the correct conversation with the patient and referred him/her to the appropriate specialist. Patients like these are very dangerous, both to themselves and to you.
Today every physician must consult with I-STOP to see if the patient is obtaining more drugs from other physicians. You must be able to document that you have made the inquiry and that the patient is not obtaining drugs from other providers. Obviously, the more drugs the patient has the more likely it is that the patient will overdose and that will probably be a nightmare for both of you.
The overriding issue is whether this patient is simply addicted to narcotics and is using you are his/her drug dealer. You cannot simply re-order narcotics visit after visit, year after year. The problem is at this point not the pain, but the drugs themselves. You have to protect yourself in this situation and get the patient to therapy. If you go it alone and simply write the prescriptions, at some point there will be a disaster and you will wonder why you did not see all this coming early in your treatment.
Be smart, protect yourself and your license.