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 become 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 opioid prescribing 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 Reduction Strategies
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.
