Overprescribing pain medicatiOn

Case Closed

a case study to help you manage risk.

presentation

In 2007, a 63-year-old man came to a family physician for a disability benefits evaluation. The patient’s medical history included coronary artery disease, morbid obesity, type II diabetes, hypertension, and hyperlipidemia.

The family physician noted that the patient occasionally had severe pain from an unhealed sternum from coronary artery bypass graft (CABG) surgery in 2003.

presentation

Current medications included: • Hydrocodone 10/325 mg, q4 PRN• Carisoprodol 350,QID• Meloxicam 15 mg QD• Tramadol 50 mg, Q4-6

presentation

The family physician continued to care for the patient, seeing him seven times from April 2008 – April 2011. All medications remained on the patients chart for these visits.

During a visit in 2010, the family physician documented a long discussion with the patient and his family who were concerned about the patient’s recent behavior: sleeping all day, up all night, overtaking his medicine, not getting out of the house, and not socializing with his family.

presentation

The family physician diagnosed chronic pain syndrome. There was no documented discussion of the patient’s odd behaviors or plan for evaluation and management of the patient’s pain. Refills for the pain medication showed lowered doses:• Carisoprodol to TID, #90• Hydrocodone to BID, #60• Tramadol to TID, #90

presentation

One month later, the patient was seen again for a cold and to discuss increasing the dose of hydrocodone from 2 to 3 pills. Carisoprodol, hydrocodone, and tramadol were refilled, each #90 with an additional refill.

The patient was seen two more times and the same three medications were refilled, same quantities of 90 with five refills. His last visit was in April 2011.

presentation

In August 2011, the patient was found dead in his home. The autopsy report listed the cause of death as “combined drug toxicity with lethal concentration of hydrocodone.”

allegations

A lawsuit was filed against the family physician. The plaintiffs alleged that the family physician prescribed excessive amounts of pain medication without indicating why the medications were being prescribed. “Further, there is no pain contract, no assessments of the cause of his pain, no urine drug screen, and no opiate drug screens.”

legal implications

This case was reviewed by two family physicians who were critical of the defendant’s care. From their review of the medical records, neither could determine why the patient was prescribed pain medication.

One reviewer stated, “Reasonable management of chronic pain includes documentation of the cause of the pain and a reasonable treatment plan with appropriate monitoring. Possible adverse effects, as well as benefits and the possibility of addiction should be discussed. Best management for chronic opioid prescribing includes a pain contract and in certain circumstances periodic urine drug screens for illicit drug use.”

legal implications

During the investigation of this claim, it was discovered that the family physician had been contacted by the patient’s pharmacy in 2009. Pharmacy staff were concerned that the patient was receiving excessive refills of tramadol. According to pharmacy records, the patient would have had to take 5 to 18 tablets of tramadol per day to justify the refills. Additionally, the patient’s family met with the family physician to discuss their concerns with the patient’s pain medication. The family physician did not alter his prescribing pattern as a result of either conversation.

legal implications

A pathologist who reviewed the case for the defense concluded that the cause of death was combined hydrocodone and tramadol toxicity.

legal implications

Certain clinician behaviors, even among honest and well-intended clinicians, substantially increase the risk that controlled drugs will be misused or abused.

• Prescribing controlled substances without obtaining a history and physical, without reviewing prior records, and without an assessment for substance use disorders.

• Prescribing multiple controlled substances or prescribing for extended periods of time without re-evaluating the indications for use.

risk management considerations

(continued)• Not monitoring the patient to detect alcohol or drug

abuse after prescribing.• Failure to consult with colleagues, such as

pharmacists and specialists, particularly experts in pain and addiction.

• Continued prescribing despite odd patient behaviors.1

All of these behaviors were exhibited by the physician described in this closed claim study.

risk management considerations

Source1. Parran TV, Wilford BB, DuPont RL. Prescription drug abuse and addiction: Clinical features, epidemiology, and contributing factors.UptoDate. April 8, 2014.

disclaimer

This closed claim is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physician(s) led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physician and the patient.© Copyright 2016 TMLT.

about tmlt

With more than 19,000 physicians in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. www.tmlt.org

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