10 tips to mitigate legal risks of opioid prescribing

Opioid-related lawsuits against physicians are on the rise. Common allegations include unnecessary prescribing, failing to heed contraindications, and missing warning signs of a likely overdose, said a Chicago -based health law attorney. To mitigate your risk of getting sued, legal and clinical experts offered the following advice:

1. Identify at-risk patients. Consider the full range of patients’ risk factors before prescribing or continuing opioids, said the director of virtual pain education at Richmond VA Medical Center in St. Petersburg, Fla., and cochair of the National VA PACT Pain Champions Initiative.

When looking at the overdose data, there used to be a perception that people who overdosed were not taking their medication as prescribed, and that’s not true all the time. In fact, in some [studies], half the people who overdose take their medication exactly as prescribed. The problems are related to dose, mixing the opioids with other medications, [patients] age, and underlying medical problems.

Ensure that therapy considerations related to opioids address the full patients picture. For example, patients with liver disease, sleep apnea, chronic obstructive pulmonary disease, asthma, and kidney disease are more prone to overdose. In addition, while nonmedical use of prescription drugs is highest in patients aged 18-25 years, opioids overdose rates are highest among patients aged 25 -54 years, according to the Center for Disease Control and Prevention.

2. Monitor midlevel providers. Closely monitor and limit opioid prescribing by the midlevel providers you supervise, said pharmacologist and consultant. A fair share of medical malpractice lawsuits result from failing to supervise a physician assistant or nurse practitioner prescribing or treating pain patients.

Develop practice protocols that track and regulate midlevel prescribing, and regularly discuss prescribing dangers with staff. Know your law; the extent to which you can prescribe varies widely.

3. Document. Keep detailed records of patients encounters that include specifics of what the patient told you.

Clear documentation about prior conditions, interactions with other health care providers, and past and current treatment help protect you should liability later arise. In the case of a dishonest patient, clear record keeping could help show that a patient lied or omitted facts if the noted later become evidence in a lawsuit.

Also [doctors] should document their policies, so there is clarity and understanding in the relationship. Showing a policy where national standards/recommendations are followed will help protect the practice.

4. Restrict refills. Require prescriber review before patients can obtain refills or new before patients can obtain refills or new prescriptions for patients who run out of medicine before their next appointment.

It’s also helpful to limit the number of pharmacies used for opioid prescriptions. This makes it easier to track medications and narrows the pathway between issuing of the prescription and drug obtainment.

5. Partner with pharmacists. Work closely with other health providers, such as psychiatrists, therapists, and pharmacists to ensure safe prescribing decision. Pharmacists have a corresponding responsibility in dispensing opiates.

Take the pharmacists’ calls regarding your opiates prescriptions. The pharmacist will know what other medicines the patient is taking and may advise of dangerous dosage or interactions.

6. Require patient agreements. Opioids treatment agreements aid in patient accountability and promote education of drug risks. In such contracts, patients agree to fully comply with all aspects of the treatment program and acknowledge that they will not use medication with harmful substances. Other terms can include those patients:

• Obtain opioids prescription from only one provider.

• Agree to keep all scheduled medical appointments.

• Promise to undergo urine drug screens as indicated.

• Agree not to share or sell medication.

• Agree not to drive or operate heavy machinery until medication-related drowsiness clears.

7. Involve family members. Family members and caregivers are critical to a patient’s opioids therapy plan. Discuss with patients ahead of time the potential for family member involvement. Family or the patient’s support system should be educated about the patient’s medications, the risks, and how to respond in an emergency.

Such communication can ensure that family members’ concerns about a patient are conveyed to physicians. Family and caregivers can also have role in improving home conditions to assist with pain management for the patient. Family education in using a naloxone rescue kit in the event of a possible overdose is essential.

8. Watch for red flags. Be cognizant of warning signs that patients may be addicted. Patients who demand medications, act impatiently about waiting for refills, or refuse to answer questions about their history should raise alarm bells. Patients who travel long distances for pain medication also should raised red flags.

Consider the criteria for opioids use disorder. The condition is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress. Signs of opioid use disorder include recurrent use by patients resulting in a failure to fulfill major role obligations at work or home, continued opioid use disorder include recurrent social or interpersonal problems caused or exacerbated by opioids, and spending a great deal of time in activities necessary to obtain the opioids, use the opioids, or recover from use, according to the American Psychiatric Association.

9. Develop an exit plan. Before starting a patient on opioid therapy, have a plan in a place in case something goes awry. Create an exit strategy that includes both pharmacologic and nonpharmacologic resources from which to draw should problems arise. Make sure you have a plan for tapering patients off opioids when necessary. This may include getting help from other clinicians in the community.

10. Do your research. Always check your state's prescription drug-monitoring program (PDMP) when prescribing on opiate to a new patient.

Perhaps most importantly, know best prescribing practices. Earlier this year, the Centers for Disease Control and Prevention released guidelines for prescribing opioids for chronic pain. Thoroughly understand the CDC guidelines.