Pain management in urgent care is a minefield of monstrous proportions. The controlled substance prescribing landscape is body trapped indeed, and the well-meaning, unsuspecting physician stands right in the middle. The regulatory, criminal and litigious nature of this highly charged issue is not to be trifled with.
Like it or not, physicians are essentially the licensees of some of the most dangerous and destructive weapons of modern medicine, and we have a clinical, legal and moral obligation to avoid BOTH under prescribing and over prescribing. To make things even more difficult, we must make these prescribing decisions based on limited information, clinical and otherwise, and do so without error. And to compound the challenge, our roles have expanded beyond our training to include investigative, enforcement, and judicial responsibilities. How do we protect our patients, our communities and ourselves from what has been inarguably called the most threatening epidemic of the 21st century? Here are several recommendations:
Policy is being made that impacts everything from the legal responsibilities of the prescriber to the development of clinical best practice. State and national organizations are eager to enlist physicians to serve at various levels. Your own Urgent Care College of Physicians (UCCOP) sent one of its board members, Dr. Sean McNeeley, to the Ohio Opiate Summit, one of the first state-supported initiatives to combat the opiate epidemic. Dr. McNeeley, on behalf of Ohio’s urgent cares and UCCOP, participated in the development of the Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances (OOCS) Prescribing Guidelines. The guidelines were endorsed by UCCOP and represent an important step toward safe and appropriate prescribing of controlled substances in the acute care setting.
Among other things, the guidelines discourage prescriptions for chronic pain, replacement prescriptions and long-acting opioids. They encourage routine use of prescription drug databases, identify verification and urine drug screens to prevent doctor-shopping and diversion. The guidelines further encourage thorough communication with consultants and primary providers as well as detailed education for patients. Lastly, they recommend a maximum 3-day supply of controlled substances when prescribed in an acute care setting.
The full guidelines and other resources can be found at: http://www.healthyohioprogram.org/ed/guidelines. Opportunities for similar initiatives in other states abound, needing only passionate torch-bearers to lead them. As you will see form the Ohio guidelines, physician involvement makes all the difference.
Establish Your Own Policies
Using the Ohio guidelines as a template, draft written policies for all your staff and physicains regarding managing and prescribing controlled substances. These policies are powerful tools for managing risk, protecting patient safety, and limiting legal exposure. Be lending a clinical rationale and the support of physician societies, written policies and educational materials can serve to defuse tension and anger from potential drug seekers.
Follow The 4 Cs of Controlled Substance Policy
When developing policy around such a charged and contentious topic, remember the 4 Cs: Clear, Concise, Conspicuous, and Consistent. Make sure your policy is clearly communicated, both in writing and orally. Keep it brief and to the point. Post it for everyone to see. And apply it consistently throughout the practice.
Following these steps will make great strides toward practicing safe and effective medicine without losing customer loyalty or creative undue disturbances in your practice. Patients and staff alike deserve a thoughtful, sensible, and respectful approach to pain management. We have a long way to go, but simple steps now can pave the way for a future of “pain-free” prescribing for all.
Lee A. Resnick, MD
JUCM, The Journal of Urgent Care Medicine