BOSTON – The line between proper prescribing of opioids and pill pushing is thin and easily crossed, forensic psychiatrists said at the annual meeting of the American Academy of Psychiatry and the Law.
The U.S. Supreme Court in 1975 ruled that physicians who are licensed by the Drug Enforcement Administration (DEA) to prescribe narcotics such as extended-release oxycodone (OxyContin) under the Controlled Substances Act are liable to prosecution "when their activities fall outside the usual course of professional practice."
But the decision about what constitutes deviation from normal professional practice might fall to the judicial system, and several high-profile cases of doctors being convicted as drug pushers have made many practitioners who would otherwise consider prescribing opioids leery of the drugs, said Dr. Gregory G. Sokolov, of the division of psychiatry and the law in the department of psychiatry at the University of California, Davis.
"There is a role for opiate medications, and there is a role for OxyContin for severe pain," Dr. Sokolov said. "Some of these cases have really scared people away from treating pain patients and prescribing opiates, and although there are going to be people who are troubled and problematic, there are patients who truly benefit from these medications."
Chronic opioid therapy is more commonly used for control of severe cancer-related pain, but appropriate non-cancer uses exist for such agents; the trick is knowing which patients will benefit, and which are malingering, said Dr. Ajay D. Wasan from the departments of psychiatry, anesthesiology, and perioperative and pain medicine at Brigham and Women’s Hospital in Boston.
"Some of these cases have really scared people away from treating pain patients and prescribing opiates."
Dr. Sokolov discussed the case of United States vs. Ronald A. McIver, D.O. Dr. McIver, who ran a pain therapy center in Greenwood, S.C., was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution, after the death of a patient with high post-mortem doses of opiates in his bloodstream.
Dr. McIver is currently serving sentences of 20 years in federal prison for distribution, and 30 years for dispensing drugs that resulted in the patient’s death. His appeals, including one made to the U.S. Supreme Court, have been rejected.
Forensic psychiatrists might be called upon to provide expert opinion in criminal cases asking whether a prescribing physician is guilty of illegally prescribing opioids for distribution or abuse, in civil actions such as malpractice cases, and in medical board investigations, including allegations of physician impairment from opioid abuse, Dr. Sokolov noted.
Prescribing and Monitoring Opioids
Clinical guidelines for the use of chronic opioids in non-cancer pain are consistent in their recommendations, Dr. Wasan said (J. Pain. 2009;10:131-46).
Key issues pain psychiatrists should consider are the patient’s comorbid psychiatric diagnoses and the ongoing psychological processes that sustain or worsen pain (for example, catastrophizing, poor coping skills, or low self-efficacy). The clinician also should consider the affective component of the patient’s pain, and whether he/she has comorbid substance use disorders or is capable of using an opioid prescription responsibly.
"So many times, psychiatrists say, ‘If the pain [were] better treated, then the psychiatric problems would go away.’ Pain physicians say that, too. But what both sides don’t quite realize is that once you develop a significant psychiatric comorbidity – even if it started because of pain, it takes on a life of its own," Dr. Wasan said.
He cautioned that, in general, opioids only should be prescribed for painful medical conditions, with the exception of methadone and buprenorphine/naloxone (Suboxone) for substance use disorders.
Prescribing opioids requires a medical evaluation and regular follow-up. The prescribing clinician should take or have on hand a full medical history of pain and underlying pathology, full physical exam, and collateral information about the patient from other providers. The patient should be reassessed on an ongoing basis, at least every 6 months.
"There is no issue with psychiatrists prescribing opioids as long as they follow these guidelines," he stated.
Opioid therapy agreements can be helpful, but must be based on mutual trust and honesty established between the patient and the physician in the first visit. Such agreements facilitate informed consent, patient education and compliance, and establish boundaries and consequences for opioid misuse or diversion. The agreement should be flexible, and not written like a contract, Dr. Wasan said.
Neither Dr. Sokolov nor Dr. Wasan reported funding sources for their studies. Both reported that they have no financial relationships pertaining to the content of their presentations.