Prescriber and Patient Opioid Responsibilities

In your opinion, regarding opioid medications, what are the rights and responsibilities of the prescriber and of the patient?

Jennifer E. Bolen, J.D.:

Jennifer E. Bolen, J.D. owns and operates a medico-legal consulting firm specializing in the development and implementation of risk management programs and practice standards for the use of controlled substances to treat pain and office-based treatment of opioid addiction. She develops educational material and educates clinicians about state and federal controlled substance and pain act guidelines, laws, policies, and regulations. Additional information about Ms. Bolen's work is available at her website www.legalsideofpain.com

A prescriber has an ethical duty to care, to do no harm, to be a good steward of his/her licenses and registrations, to the pain community, and to his/her patients, and to not abandon patients. A prescriber must only prescribe controlled substances for a legitimate medical purpose in the usual course of professional practice, and with an eye to minimizing the potential for abuse and diversion of controlled substances. A prescriber has the right to say no when treatments requested exceed the scope of his/her practice, but this comes with a duty to help the patient find providers who might be able to help the patient.

Similarly, patients owe a duty of communicating accurate and complete information to providers and to be a good steward in terms of putting forth a genuine effort to attain treatment plan goals and responsibly handle any medications. A patient has a right to have his/her pain assessed and treated, but a patient cannot force a prescriber to treat outside the scope of his/her practice. Of course these rights and responsibilities are much more specific in terms of subtopics, but these are the topline issues.

Both prescribers and patients have should discuss their respective roles openly and honestly, and work together to achieve the best patient outcome. Pharmacists have similar responsibilities as prescribers. Unfortunately, the different information available to help clinicians, provided by federal agencies and legal entities, and individual state and legal entities, and advocacy groups and professional medical organizations, can lead to confusion and anxiety. A common example is the variety of information relating to and potential confusion surrounding the issue of whether there are quantity limits on the amount of controlled substances that can be prescribed in a single prescription. The Federal government has not set any limitation on quantities, but some states have set specific limits.

Health care clinicians need to understand the interplay of law and medicine or they can get in trouble. State and federal guidelines are available at no cost via the Internet to everyone. There are often educational audio "town halls" on my website (above). Good resources for information are the Pain & Policy Studies Group at the University of Wisconsin and my columns in back issues of Pain Management News.

Prescribers need to learn how to incorporate key phrases from state and federal regulations into the medical record. Forms are not magic, but the intent of any form should be to communicate the relevant clinical information in a manner that demonstrates compliance with federal and state legal/regulatory materials. When prescribing opioids, it is important that the clinician review minimal requirements outlined by his/her medical licensing board and determine whether his/her documentation reflects knowledge of and compliance with these terms. One area that is especially critical relates to the evaluation of the patient and whether there is indeed a legitimate medical reason for the use of a controlled substance to treat the patient's pain. If there is, then the prescriber should engage in an informed consent discussion with the patient to ensure the patient understands the potential risks, expected benefits, available treatment alternatives, and special issues associated with the use of the recommended medication. The prescriber should make a note (or use a form) to reflect the informed consent discussion.

Patients need to be honest with themselves as well as to their clinicians, about when they need to take medication and when they can manage with less. Unfortunately, most patients think they have to complain in order to assure that their medication will continue to be prescribed. Management of pain works best when the patient and prescriber have a relationship with good communication. It is very helpful for a patient to keep a good record of how they are balancing their pain medication, managing side effects, and achieving their goals. Patients should understand that while it makes sense to ask their doctor for a few days leeway between prescriptions, to account for life events and schedules, it is not wise to "stockpile" medication, as this may pose a threat that knowledge about this may jeopardize the relationship with their clinician.

At the same time, the clinician needs to reassess the patient at every visit, which may or may not require a physical examination, to understand whether there is an ongoing clinical need for the medication and whether the patient is working toward treatment plan goals. For example, a patient who finds it helpful to use a new rapid onset medication for breakthrough pain may be able to decrease their usual prescription of breakthrough medication, and information like this is significant and should be documented in the medical record.

I believe the physician-patient relationship as it relates to the use of controlled substances to treat pain is about trust and working together in a way that balances the patient’s legitimate need for controlled substances with the prescriber's responsibility to minimize the potential for abuse and diversion in relation to his/her duty to care/treat and to do no harm, etc.

Everyone in the medical practice should understand and follow the same consistent policy for management and communication, including front desk staff. The practice where I get medical care asks patients to receive all of their medications at one pharmacy. I have no trouble complying with this request. However, on at least three occasions, the pharmacy I chose did not have the medications I take and I needed to obtain my medications before I left town for an extensive period. I called my doctor's office and left a message on the nurse's line stating that I wanted to switch to a new pharmacy in the same pharmacy chain, because the new pharmacy regularly stocked the medication I use. I also told the individual who answered the phone at the front desk. Despite my efforts, I was told that I could only do this "once" and that if I did it again I could be discharged from the practice. I informed my doctor of this event and it was quite clear that he had no problem with my switching pharmacies or with the way I informed his office. In the end, it was also clear that he did not realize that a member of his staff was communicating with patients in a way that was perceived as punitive.

The prescriber and his/her staff should discuss issues like switching pharmacies and work to minimize the potential for miscommunications and behaviors that may erode the physician-patient relationship. It is important to remember that both parties have a duty of stewardship as it relates to the responsible prescribing and use of controlled substances and strive to keep communication lines open throughout the treatment period.