Dismissing a Patient with Chronic Pain and Opioid Dependency Leads to Allegation of Abandonment

Terminating treatment of a chronic pain patient can become complicated, even when a patient agreement is signed and the termination letter is sent.¹

Case File

A 31-year-old woman presented to a pain management specialist. She reported a 10-year history of acute abdominal pain. Her prior physician had prescribed 600 mg of controlled-release oxycodone per day, which she reported was not adequately controlling her pain. She did not tell her new physician that she had been through opioid dependency treatment three times, had a history of alcoholism, purchased and sold opioids on the street and “doctor-shopped” for narcotics. She signed an opioid analgesic therapy agreement and began pain management treatment with her new physician.

For the next year, the patient saw the physician approximately every two weeks. She regularly requested additional pain medications for various reasons. Because she reported inadequate pain relief, the physician gradually increased her oxycodone dosage. By the end of a year, he was prescribing 2000 mg of oxycodone per day.

The physician decided to stop his opioid prescribing and dismiss the patient after being informed that she had fraudulently filed a police report claiming her oxycodone had been stolen. The physician sent the patient a certified letter dismissing her from his care based on her violation of the pain medication agreement. He included the names of two physicians he thought might be willing to take over her treatment. He also prescribed one month’s supply of oxycodone. The patient committed suicide 10 days later.

The patient’s family filed a malpractice lawsuit against the physician alleging, among other claims, negligent opioid prescribing and that he abandoned the patient when he dismissed her from his practice.

Discussion

Having a patient sign a pain medication agreement and following other risk management recommendations won’t always keep a patient from filing suit, but documenting evidence of a patient’s noncompliance with an agreement can support a clinician’s decision to withdraw from treatment. Although this lawsuit proceeded on other negligence issues (i.e., the level of narcotics prescribed, the necessity of a referral to a specialist, etc.), the physician’s proactive risk management in this case facilitated the early dismissal of the abandonment claim.

Risk Reduction Strategies

Consider the following recommendations:

• Have the patient sign a pain medication agreement after providing an informed consent process including not only the risks, benefits and alternatives of opioid treatment, but also the consequences of non-adherence to the agreement.
  • A pain medication agreement can reinforce your therapeutic expectations, prescribing rules, assessment protocols, legal requirements and grounds for patient dismissal.
    • Policyholders can obtain a sample pain medication agreement by contacting a risk management specialist.
  • When aberrant drug-related behavior is suspected, ensure that the following steps have been taken and documented prior to starting the termination process:
    • Conduct an in-depth assessment to determine whether aberrant behavior is caused by addiction (“a maladaptive pattern of use that includes impaired control over use, compulsive use caused by craving, and continued use despite harm”²) or pseudo addiction (a patient’s need for more pain medication due to inadequate pain relief). If addiction is suspected:
      • Discuss with the patient your concern about his or her apparent misuse/abuse of pain medication.
      • Offer appropriate alternative pain management.
      • Offer referral to addiction support, if appropriate.
    • Document and refer the patient to a mental health specialist when behaviors are suggestive of the risk of suicide or the presence of concomitant major mental health diagnoses.

References

1. Case study derived from Fishbain DA, et al. Alleged Medical Abandonment in Chronic Opioid Analgesic Therapy: Case Report. Pain Med. 2009 May-Jun;10(4):722-9.

2. Heit HA. Creating and implementing opioid agreements. Dis Manage Digest. 2003;7:23.