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Managing the Risks of Treating Chronic Pain with Opioids

July 6, 2017

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.

doctor discussing opioid prescriptions with a patient

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.

For the latest CDC guiding principles and recommendations for opioid prescribing, see the 2022 Clinical Practice Guideline for Prescribing Opioids for 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.
This content originally appeared in Claims Rx, our claims-based learning publication available in the searchable Claims Rx Directory. Many releases are available for download and eligible insureds will find instructions for obtaining CME credit for select releases.

Filed under: Pain Management, Prescribing & Medication, Best Practices, Physician, Opioids



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