Managing the Risks of Treating Chronic Pain with Opioids

By Jane Mock, Risk Management Specialist Medicus Insurance Company, A NORCAL Group company

Physicians need to be especially careful when managing chronic pain with opioid medications. Medical practices often seek risk management advice when they suspect a patient is misusing prescription medications, is not complying with treatment, or when the patient is making unreasonable demands for more opioids. If a patient suffers harm as a result of opioid medication use, a physician may find himself the target of a lawsuit alleging negligent treatment of chronic pain.

How Does the Management of Opioids Create Potential Liability?
Claims against physicians for negligent treatment and/or management of opioid medications frequently arise from the following:

• Prescribing opioids without performing any diagnostic examinations
• Prescribing an excessive quantity of opioids
• Prescribing additional narcotics when not indicated
• Failing to consider, screen for, or suspect narcotic addiction, and failing to refer the patient for treatment of drug addiction   
• Negligent monitoring
• Failing to consult or refer to a pain specialist

Is the Story Clear?
The physician might think that he or she has managed a patient’s pain appropriately, but if the medical record documentation does not reflect that, defense of care is difficult. Examples of poor documentation include:

• No indication that the treating physician reviewed the patient’s prior medical records or studies
• No physical exam results
• No quantitative assessments of the patient’s pain
• No indication that the treating physician discussed the risk of opioid addiction
• No pain medication agreement
• No evidence of assessment of effectiveness of the pain medications
• No rationale for the physician’s medication choices
• No copies of narcotic prescriptions

Risk Management Tips
Clinicians can avoid reaching a point of crisis by applying a risk management approach to treating chronic pain.

Perform and document a comprehensive history and physical examination of the patient.

• Complete all indicated diagnostic exams and tests.
• Use an objective, comprehensive pain assessment tool.
• Evaluate the patient for his or her risks of abusing medication.
• Request copies of prior medical records. Base the treatment plan on the patient’s individual needs.
• Document differential diagnoses.
• Consider and try both pharmacologic and non-pharmacologic pain treatments.
• Manage patient expectations and educate patients about physical dependence, tolerance, and addiction. Document this discussion, as well as a plan of action to address physical dependence.
• Document clinical decision making and rationale for one treatment choice over another.
• Have patient sign a pain management agreement, if indicated.

Re-evaluate and document the patient’s level of pain and response to treatment at each visit.
• Consider having the patient keep a pain diary.
• Note the effectiveness and patient compliance with various treatment modalities
• Document the patient’s response, changes to the treatment plan, and your clinical rationale.
• Document the name of the drug, dose, frequency with which the patient has been taking the medication; reported effectiveness; and the impact on the patient’s daily activities.
• Communicate with other providers who are treating the patient.
• Strongly consider utilizing your state’s prescription drug monitoring program
• Utilize and refer to specialists when appropriate.
• Be familiar with local resources that can provide assistance (e.g., pain clinics, teaching hospitals).
• Obtain second opinions when indicated.
• When choosing not to pursue clarification of a symptom or complaint, document the rationale.

Be aware of signs of drug abuse or misuse.
• Set limits with patients; consider using a therapeutic pain medication agreement.
• Do not provide narcotic refills unless the patient comes in for re-assessment.
• Evaluate the appropriateness of the requests in light of the prescription provided.
• If you suspect substance abuse, carefully document details of the situation and discussions with the patient in the patient’s medical record.

Monitor the patient’s non-compliance.
• Enforce the pain management agreement, when indicated.
• Document the patient’s action or inaction that led to termination or discontinuation of pain medications and rationale for the decision.
• Contact your medical professional liability insurer’s risk management department for guidance relating to terminating a patient from the practice.

 

Copyright 2014 NORCAL Mutual Insurance Company, parent company of Medicus Insurance Company. All rights reserved. This material is intended for reproduction in the publications of NORCAL-approved producers and sponsoring medical societies that have been granted prior written permission. No part of this publication may be otherwise reproduced, edited or modified without the prior written permission of NORCAL. For permission requests, contact: Jo Townson at (800) 652-1051, ext. 2270.

The information contained in this document is intended as risk management advice. It does not constitute a legal opinion, nor is it a substitute for legal advice. Legal inquiries about topics covered in this document should be directed to an attorney. Recommendations contained in this document are not intended to determine the standard of care, but are provided as risk management advice. Recommendations presented should not be considered inclusive of all appropriate risk management strategies or exclusive of other strategies reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the individual physician/healthcare provider in light of the individual circumstances presented by the patient.