Doing our part to encourage responsible prescribing of controlled substances
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Safe and appropriate prescribing of controlled substances remains a top concern of the North Carolina Medical Board. In each of the past five years, about 30 percent of all public actions taken against licensees related to prescribing problems. The vast majority of these involved controlled substances. As the number of prescriptions for controlled substances prescribed in North Carolina continues to rise, it seems likely that the number of Board actions will also increase.Sometimes the prescribing we review is clearly excessive and inappropriate. Last year, for example, the Board indefinitely suspended the license of a physician whose prescribing led multiple pharmacists and other professionals to report the physician to the Board.
The Board’s investigation found that the physician wrote prescriptions for Diazepam, Hydrocodone, Oxycodone, Oxycodone ER, Temazepam, Alprazolam and Tussionex liquid over a period of 16 months to a single patient. The patient used multiple pharmacies to obtain these drugs. A NC Controlled Substances Reporting System (NCCSRS) query of the patient’s prescription history found 117 separate entries (each entry representing a prescription for controlled substances dispensed) for the 16-month period reviewed. In a second instance, the physician prescribed 360 Oxycodone HCL 15mg tablets to a patient and then, just two days later, prescribed 720 Oxycodone HCL 30mg tablets to the same person. A third example of the physician’s excessive prescribing involved a high school student who was being prescribed Xanex and Vynase. A school social worker reported the student often slurred his words and would sometimes fall asleep in the middle of a conversation. The same student allegedly sold some of the medications prescribed by the physician. When the school refused to continue to administer the student’s medications, the physician sent the school a letter stating there was “no risk” in giving the student the prescribed drugs.
Cases like this one, where prescribing is clearly substandard (as confirmed by independent expert medical reviewers) and the physician appears not to recognize or acknowledge problems with care are rare. Far more often, issues with prescribing are more subtle and the licensees in question are well meaning medical professionals who have ventured into the treatment of chronic pain out of a genuine desire to help patients. Problems arise when these licensees don’t know appropriate standards of care and then engage in potentially unsafe prescribing.
The Board’s duty to protect the public obligates it to not only to stop unsafe prescribing practices, but also to promote safe and appropriate prescribing. Some of our efforts to encourage proper prescribing include publishing informational articles in this newsletter. We post information about obtaining free or low-cost CME in the area of prescribing controlled substances for chronic pain on the Board’s website. The Board also frequently recommends “Responsible Opioid Prescribing: A Clinician’s Guide” by M. Scott Fishman, MD, which is considered the national gold standard publication for prescribing opioids. In NC, however, the foundation for safely prescribing controlled substances is the Board’s position statement, “Policy for the use of controlled substances for the treatment of pain.”
The Board adopted this position statement in July 1996 and completely revised it in July 2005 based on the “model policy” on the treatment of chronic pain developed by the Federation of State Medical Boards (FSMB). Given the rapid changes occurring in controlled substance use and prescribing, the Board is currently reviewing and revising the position statement again.
Over the past few years, the Board has sought opinions from its licensees and others when revising position statements and rules. To continue this outreach, the NCMB will host a public forum on the subject of prescribing controlled substances for the treatment of pain at its offices in Raleigh on August 21st, between 4 and 6 p.m. The Board will consider these comments and suggestions as it develops the latest revision of its position statement. If you are unable to attend, you may submit comments by August 30 to forum@ncmedboard.org
To help licensees understand this important policy discussion, we have dedicated most of this issue of the Forum to the subject of controlled substances. We have published the full text of the Board’s existing position statement. We’ve also published a draft of the FSMB’s new “Model Policy on the Appropriate Use of Opioid Analgesics in the Treatment of Chronic Pain,” which will be an important resource for the Board during the review and revision process. A distinguished panel of physicians and recognized experts in the field developed the draft FSMB policy after a months-long study of current issues as well as trends and standards of care in the treatment of chronic pain I’m proud to say that two North Carolina physicians—Janelle Rhyne, MD, a past president of this Board and past chair of the FSMB, and the NCMB’s Associate Medical Director C. Michael Sheppa, MD,—participated in this workgroup. State medical boards often use FSMB’s model policies as starting points when tackling complex issues such as the use of opioids in the treatment of pain.
Finally, I am happy to report that this summer’s legislative session improved the NC Controlled Substances Reporting System law (NCCSRS). The NCCSRS allows licensees to appropriately review their patients’ controlled substances prescription histories. Prior to the revision, the law required the prescriber to personally conduct all queries. In June, Governor McCrory signed Senate Bill 222 into law. As adopted, the law authorizes physicians and other registered users of the NCCSRS to delegate queries to designated persons in the practice, provided those persons register for access to the database. Although the change will take several months to implement, when completed, obtaining reports from the NCCSRS will be much easier and faster.
To promote responsible prescribing, the NCMB encourages licensees to register with the NCCSRS and use it regularly. The NCCSRS helps physicians and PAs avoid prescribing controlled substances to patients who may have received multiple prescriptions from other providers. Please read the article on the pending changes to the NCCSRS on P. 7.
I urge you to take the time to learn more about controlled substance prescribing. Participating in the Board’s policy discussion around appropriate prescribing of controlled substances for pain allows you to have a voice in creating Board policy. If you are treating pain in your practice, make sure you have current and complete information about controlled substance prescribing. Don’t be a well-meaning but uninformed prescriber who unintentionally adds to the epidemic of prescription drug misuse and abuse.
Send comments to forum@ncmedboard.org
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Public forum
Where: NCMB offices, 1203 Front Street, Raleigh, NC 27609
When: Wednesday, August 21, 4-6 p.m.
Why: NCMB is reviewing and revising its position statement on treating chronic pain
Who should attend: Licensees and other interested parties
Complete a one-question survey.
How often do you prescribe controlled substances to treat chronic pain?
Comments on this article:
I was recently strongly chastised by a hospital administrator for prescribing a resident of a nursing home, who had been taking large doses of an oral opiate for chronic pain, 4 doses of IM Demerol, 100 mg every 6 hours. I did this to prevent withdrawal while awaiting an appointment with a physician who would manage the chronic pain. I am totally frustrated regarding the liability of prescribing pain medications and am reluctant to prescribe anyone more than a small amount of anything on a one-time basis. I am approaching the point where I believe all opiates should be taken off the market so physicians will no longer be liable for all of the misuse of these substances. I feel like telling patients that they can get heroin without a prescription when they tell me they cannot live without 450 mg of oxycodone daily. There is no such thing as responsible prescribing of opiates. As long as they are available, they will be abused and physicians will be blamed.
By Laurence Schlanger on Aug 07, 2013 at 12:24pm
I would like the NC Med Board to follow the lead of Ohio and REQUIRE prescribers to check the database.
Ohio requires checking:
(1) If a patient is exhibiting signs of drug abuse or diversion;
(2) When you have a reason to believe the treatment of a patient with controlled substances or tramadol will continue for twelve weeks or more; and
(3) At least once a year thereafter for patients receiving treatment with controlled substances or tramadol for twelve weeks or more.
To me this seems reasonable and prudent. The goal is to protect the public health and provide effective pain management with opioids to appropriate patients.
By Gary Sims, DO on Aug 08, 2013 at 8:59am
How come no one ever mentions the “P” word when discussing problems with controlled substance prescribing? After all, drug PROHIBITION is the reason for all these problems (there, I’ve said it…). Almost 100 years of drug prohibition (and the misinformation that comes from it) have left the US population completely ignorant about psychoactive drugs and at risk from the underground market. And with the lack of legitimate jobs, the diversion of controlled prescriptions provides needed income for many families across the state. Thus overdoses and deaths occur in NC at an alarming rate. At least diverted prescription drugs are standardized and quality-controlled. Still, two 10mg methadone tablets along with some ethanol can be fatal to an opiate-naive person. I always stress the dangers of a prescription - including diversion - to my patients, especially those with children or teens around.
By James Stewart Campbell, MD. on Aug 08, 2013 at 11:50am
P.S.: The Forum article cites overprescribing of “...Xanex and Vynase…”? Do you mean Xanax (alprazolam) and Vyvanse (lisdexamfetamine)? - jc,md.
James Stewart Campbell, MD.
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