In April 2011, the Office of National Drug Control Policy declared the American opioid abuse problem an epidemic. Robert Saenz, CEO of Tulsa Pain Consultants, president of VIP Medical Consulting and former Federal agent, says physicians need to be more vigilant than ever because they are going to be held more accountable.
"Because of this epidemic, doctors need to be aware that there's a crisis," he says. "The federal government is looking at this, and they're going to hold physicians a lot more accountable than before because there's going to be more resources to do that."
Mr. Saenz has developed a training program to advise physicians how to protect their practices from opioid abuse and diversion. He first implemented the program at Tulsa Pain Consultants and is now working to implement the program in practices across the country.
Andrew F. Revelis, MD, a physician at Tulsa Pain Consultants, worked with Mr. Saenz on implementation and says drug abuse and diversion are always risks in pain management clinics.
"It's something inherent in the nature of the work we do," he says. "We have always been mindful of that, and we're trying to be preemptive. It's an issue that many of the pain clinics are facing around the country. With the proliferation of new pain drugs, people are being more aggressive treating pain, and there is a subset of patients who are accessing these clinics and getting the drugs, and then they are sold to other folks. This is a supply that we control as physicians, and we have a responsibility to safeguard these medications."
Mr. Saenz says he occasionally receives pushback from physicians who see themselves as caregivers only and do not want to take responsibility for opioid abuse.
"Unfortunately, doctors are being duped more so and more so," he says. "Seven million people are abusing prescription medication. Some are abusing it and hurting themselves or diverting it. It's a very turbulent time to be completely a caregiver and not someone who's being completely vigilant. We're not asking physicians to be police officers, but we are asking them to be more diligent in how they distribute these medications."
Mr. Saenz and Dr. Revelis offer five opioid abuse and diversion safeguards for a pain management practice.
1. Have patients sign opioid agreements. Asking patients to sign an opioid agreement is standard procedure at many pain clinics, says Mr. Saenz.
"This not only requires them to only receive pain medication from our clinic, it also lets them know that we will randomly do urine analysis," says Dr. Revelis. "It's a justification to ask them to leave our care if these rules are violated."
Mr. Saenz recommends that physicians call it an agreement rather than a contract because of certain legal issues that can arise by using the word contract. The agreement should stipulate things such as not taking drugs from any other physicians, not mixing drugs, not drinking alcohol with the drugs and not giving the drugs to any other individual, as well as a clause that says the patient can be discharged from treatment for not following these rules.
2. Give patients urine drug tests. Patients are given a urine drug test when they first come to Tulsa Pain Consultants, and they are periodically given UDTs as the physicians see fit. Mr. Saenz says the UDTs are to make sure the patients are taking the prescribed drugs. The presence of medication in the urine can be tested in the office, but the sample should be sent to an outside lab to check the levels of the medication and verify the results of the in-office analysis. If patients are not taking their medication, this doesn't mean they are selling it, Mr. Saenz says. The important thing is to have a conversation with the patients to figure out why the medication is not being taken. The reason could be as simple as adverse side effects.
3. Use prescription drug databases. The National All Schedules Prescription Electronic Reporting law, which provides for the creation of a prescription monitoring database in each state, was passed in 2005, but funding has been sporadic. Currently, 37 states have active databases. Mr. Saenz sees the databases as another tool for physicians to protect against opioid abuse and diversion.
"If you have a website in your state and you're not using it, shame on you," he says. "That's one of your best tools."
He guarantees that federal authorities will look at whether physicians are checking the database before prescribing drugs to patients. Not only should physicians check the database, they should document it. Some of the databases allow physicians to print the records to insert into a patient's chart. If printing is not allowed, physicians should make a note of the date the database was checked and what information was found.
Mr. Saenz says in some cases, physicians will come across a patient who has received drugs from other physicians. In nine out of 10 cases, he says, that physician will not call the other provider. This is a lost opportunity, he says. It's possible that the physician prescribed medication to the patient or that someone is writing fraudulent prescriptions using that physician's name. Either way, it helps to talk to one another, he says.
4. Conduct criminal background checks, if necessary. Although Mr. Saenz does not recommend this for every patient that comes to a pain management clinic, it's good to leave the option open. For this reason, he does recommend that the intake paperwork includes a clause that tells the patients criminal background checks might be done.
He recommends a criminal background check in the case of a patient who has turned up red flags in a database search, whose urine drug analysis was off or who is exhibiting abhorrent behavior, such as being argumentative or asking for a specific drug.
5. Keep proper documentation. The most important way to protect a practice against drug abuse and diversion is to do due diligence and keep proper documentation, Mr. Saenz says. For example, if a physician receives an abnormal result on a urine analysis, mark it in the chart. Mr. Saenz says physicians often fail to document their own observations about patients in their charts.
"It's very important when you're dealing with a person on opioids to document your observations," he says.
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"Because of this epidemic, doctors need to be aware that there's a crisis," he says. "The federal government is looking at this, and they're going to hold physicians a lot more accountable than before because there's going to be more resources to do that."
Mr. Saenz has developed a training program to advise physicians how to protect their practices from opioid abuse and diversion. He first implemented the program at Tulsa Pain Consultants and is now working to implement the program in practices across the country.
Andrew F. Revelis, MD, a physician at Tulsa Pain Consultants, worked with Mr. Saenz on implementation and says drug abuse and diversion are always risks in pain management clinics.
"It's something inherent in the nature of the work we do," he says. "We have always been mindful of that, and we're trying to be preemptive. It's an issue that many of the pain clinics are facing around the country. With the proliferation of new pain drugs, people are being more aggressive treating pain, and there is a subset of patients who are accessing these clinics and getting the drugs, and then they are sold to other folks. This is a supply that we control as physicians, and we have a responsibility to safeguard these medications."
Mr. Saenz says he occasionally receives pushback from physicians who see themselves as caregivers only and do not want to take responsibility for opioid abuse.
"Unfortunately, doctors are being duped more so and more so," he says. "Seven million people are abusing prescription medication. Some are abusing it and hurting themselves or diverting it. It's a very turbulent time to be completely a caregiver and not someone who's being completely vigilant. We're not asking physicians to be police officers, but we are asking them to be more diligent in how they distribute these medications."
Mr. Saenz and Dr. Revelis offer five opioid abuse and diversion safeguards for a pain management practice.
1. Have patients sign opioid agreements. Asking patients to sign an opioid agreement is standard procedure at many pain clinics, says Mr. Saenz.
"This not only requires them to only receive pain medication from our clinic, it also lets them know that we will randomly do urine analysis," says Dr. Revelis. "It's a justification to ask them to leave our care if these rules are violated."
Mr. Saenz recommends that physicians call it an agreement rather than a contract because of certain legal issues that can arise by using the word contract. The agreement should stipulate things such as not taking drugs from any other physicians, not mixing drugs, not drinking alcohol with the drugs and not giving the drugs to any other individual, as well as a clause that says the patient can be discharged from treatment for not following these rules.
2. Give patients urine drug tests. Patients are given a urine drug test when they first come to Tulsa Pain Consultants, and they are periodically given UDTs as the physicians see fit. Mr. Saenz says the UDTs are to make sure the patients are taking the prescribed drugs. The presence of medication in the urine can be tested in the office, but the sample should be sent to an outside lab to check the levels of the medication and verify the results of the in-office analysis. If patients are not taking their medication, this doesn't mean they are selling it, Mr. Saenz says. The important thing is to have a conversation with the patients to figure out why the medication is not being taken. The reason could be as simple as adverse side effects.
3. Use prescription drug databases. The National All Schedules Prescription Electronic Reporting law, which provides for the creation of a prescription monitoring database in each state, was passed in 2005, but funding has been sporadic. Currently, 37 states have active databases. Mr. Saenz sees the databases as another tool for physicians to protect against opioid abuse and diversion.
"If you have a website in your state and you're not using it, shame on you," he says. "That's one of your best tools."
He guarantees that federal authorities will look at whether physicians are checking the database before prescribing drugs to patients. Not only should physicians check the database, they should document it. Some of the databases allow physicians to print the records to insert into a patient's chart. If printing is not allowed, physicians should make a note of the date the database was checked and what information was found.
Mr. Saenz says in some cases, physicians will come across a patient who has received drugs from other physicians. In nine out of 10 cases, he says, that physician will not call the other provider. This is a lost opportunity, he says. It's possible that the physician prescribed medication to the patient or that someone is writing fraudulent prescriptions using that physician's name. Either way, it helps to talk to one another, he says.
4. Conduct criminal background checks, if necessary. Although Mr. Saenz does not recommend this for every patient that comes to a pain management clinic, it's good to leave the option open. For this reason, he does recommend that the intake paperwork includes a clause that tells the patients criminal background checks might be done.
He recommends a criminal background check in the case of a patient who has turned up red flags in a database search, whose urine drug analysis was off or who is exhibiting abhorrent behavior, such as being argumentative or asking for a specific drug.
5. Keep proper documentation. The most important way to protect a practice against drug abuse and diversion is to do due diligence and keep proper documentation, Mr. Saenz says. For example, if a physician receives an abnormal result on a urine analysis, mark it in the chart. Mr. Saenz says physicians often fail to document their own observations about patients in their charts.
"It's very important when you're dealing with a person on opioids to document your observations," he says.
Related Articles on Pain Management:
16 New Pain Management Facility Openings in 2011
Pain Management Physicians: What Technology or Practice Management Tool Do Pain Management Practices Need to Adopt in 2012?
Pain Physicians: What Procedure Was Most Helpful for Your Patients in 2011?