APPROPRIATE PRESCRIBING OF CONTROLLED SUBSTANCES – STRATEGIES TO PROTECT YOUR PRACTICE

1. APPROPRIATE PRESCRIBING OF CONTROLLED SUBSTANCES – STRATEGIES TO PROTECT YOUR PRACTICE

2. COMPOSITE STATE BOARD OF MEDICAL EXAMINERS • FOR INFORMATION AND TO CONTACT THE BOARD: • 2 PEACHTREE STREET, NW 36TH FLOOR ATLANTA, GA 30303 (404) 463-0635 http://medicalboard.georgia.gov

3. LEARNING OBJECTIVES • To recognize the elements of a valid physician/patient relationship • To recognize certain patient behaviors that may indicate abuse • To recognize the importance of thorough documentation • To become familiar with the law and rules governing the prescribing of controlled substances

4. REGULATION • Gov’t. makes controlled substances available under defined, restricted conditions • Controlled substances are available for a legitimate medical purpose • Controlled substances are available to treat legitimate medical illness/conditions

5. GEORGIA LAW CONCERNING CONTROLLED SUBSTANCES • OCGA TITLE 16 constitutes the GA Controlled Substances Act • OCGA 16-13-41 deals with the proper prescribing of controlled substances

6. OCGA 16-13-41 • Paragraph (f) states: No person shall prescribe or order the dispensing of a controlled substance, except a registered practitioner who is: • Licensed or otherwise authorized to prescribe controlled substances; • Acting in the usual course of his professional practice; and • Prescribing or ordering such controlled substance for a legitimate medical purpose.

7. US SUPREME COURT • In a 1973 case the US Supreme Court stated: “A licensed practitioner is not immune from the law solely due to his status….but rather, because he is expected to prescribe or dispense drugs within thebounds of his professional practice of medicine. A physician is restricted to dispensing or prescribing drugs in the bona fide treatment of a patient’s disease…However, under the guise of treatment a physician cannot sell drugs nor distribute drugs intended to cater to the cravings of an addict…Congress did not intend for doctors to become pushers.”

8. GA LAW-MEDICAL PRACTICE ACT • OCGA 43-34-37(a)(7) • The Board may discipline a physician if he/she has… “engaged in any unprofessional, unethical, deceptive, or deleterious conduct or practice harmful to the public…..”

9. BOARD RULES • Board rules/regulations help define “unprofessional conduct” • Board Rule 360-3-.02 defines unprofessional conduct to include, but not limited to……

10. 1) Prescribing controlled substances (CS) for a known or suspected habitual drug abuser or other substance in the absence of substantial justification • 2) Writing prescriptions for CS for personal use or, except for documented emergencies, for immediate family members (spouse, children, siblings, parents)

11. 3) Prescribing, ordering, dispensing, administering, selling, or giving any amphetamine, sympathomimetic amine drug designated as CII to or for any person except in the following situations: • ADD • Drug induced brain dysfunction • Narcolepsy • Epilepsy • Depression or other psychiatric diagnosis

12. 4) Pre-signing prescriptions that have the patient’s name, type of medication, or quantity blank • 5) Prescribing CS and/or dangerous drugs for a patient based solely on a consultation via electronic means with the patient… (documented emergencies, on-call, and/or covering for another physician notwithstanding)

13. 6) Failing to maintain appropriate patient records whenever CII, CIII, CIV, or CV controlled substances are prescribed. • At a MINIMUM, records shall contain: • Patient’s name and address • Date, drug name, quantity, and diagnosis necessitating the particular CS’s; and • Records concerning the patient’s history

14. RETAIL STREET PRICESLOS ANGELES CRIMINAL INFORMATION CLEARINGHOUSE • KETAMINE 10ML VIAL $100-$200 • KETAMINE .2 GRAMS $20 • XANAX 4MG TABLET $1-$5 • ADDERALL/RITALIN 10 MG TAB $10-$25 • VICODIN ES 10MG TABLET $1-$10 • OXYCONTIN 80MG TABLET $50-$80 • PERCOCET/PERCODAN 5MG $1-$5 • DILAUDID 4MG TABLET $20-$60 • MS CONTIN 60 MG TABLET $20 • DURAGESIC PATCH $25-$100

15. WHAT CONSTITUTES LEGITIMACY? • ONE PRIMARY QUESTION TO ASK YOURSELF: “Does there exist a valid physician/patient relationship?”

16. WHAT CONSTITUTES A VALID PHYSICIAN/PATIENT RELATIONSHIP? • 3 PRIMARY COMPONENTS: • The patient must desire treatment for a legitimate illness or condition; • The physician must make a reasonable effort to determine the patient’s legitimate medical needs via history, physical, testing, etc.; • There must be a reasonable nexus between the drugs prescribed and the patient’s legitimate medical needs.

17. 1st COMPONENT • Is the patient sincere in seeking treatment for a valid illness or condition? • Am I as a physician competent to diagnose and treat this condition? • Does the patient really have a legitimate medical problem?

18. 2nd COMPONENT • What does this patient need from a medical standpoint? • What examinations and tests should be performed to accurately diagnose the problem? • What questions must be asked regarding symptoms, course of illness, previous treatments and other medical problems?

19. 3rd COMPONENT • Is drug treatment warranted and if so, which ones, at what dosage, and for how long? • Are the drugs I am about to prescribe the proper treatment for this patient?

20. PATIENT BEHAVIORS TO CONSIDER • Resides out of town or out of state • Requests specific drugs, usually by brand name • Relates obviously unjustified reasons for needing the requested drug • Responds that a recommended drug causes adverse reactions or has not worked in the past • Resists examination and diagnostic testing • Restive behavior and attempts to prematurely conclude the encounter

21. PATIENT BEHAVIORS (CONTINUED) • Arrives after hours or at closing • Unable to give name of regular physician • Claims to have no health insurance • Claims to have lost prescription or that it was stolen • Exaggerates medical problems or feigns them • Recites textbook symptoms or gives vague medical history

22. DOCUMENTATION IT IS IMPERATIVE THAT YOU THOROUGHLY DOCUMENT ALL ENCOUNTERS WITH ALL PATIENTS, SUCH AS: • Patient discussions • Physical examinations • Tests and results • Consultations • Referrals

23. DOCUMENTATION (CONTINUED) • Accurate details regarding drugs prescribed • Quantities • Dosages • Refills authorized • Patient instructions

24. TIPS TO CONSIDER • Secure all prescription blanks to avoid theft. • Minimize the number of prescription pads in use at any given time. • Write in indelible ink. • Record the number of doses in script and Arabic (or Roman numerals) to avoid alteration. • Avoid prescribing large quantities if not necessary.

25. TIPS TO CONSIDER (CONTINUED) • Maintain only a minimum stock of controlled substances in the office. • Be cautious when another physician has been prescribing for the patient. • Consult with this physician. • Use prescription pads for prescribing, not as a note pad. • NEVER sign a blank prescription in advance.

26. ELECTRONIC PRESCRIBING • CURRENT GUIDELINES FOR ISSUING PRESCRIPTIONS ELECTRONICALLY: • 1) MUST BE PRINTED ON SECURITY PAPER • 2) MUST STATE THAT THE RX WAS SIGNED ELECTRONICALLY BY THE RX’ING PHYSICIAN

27. Your medical license grants a privilege to practice medicine. Other than your integrity and ethics, it is perhaps your most valuable asset. Protect it. Be cautious and thorough.