Tuesday, December 8, 2015

Changing Face of Pain Treatment - a Game Changer?

I have noted before that many of the issues we face in workers' compensation do not necessarily make it into the national media.

But pain medication is starting to finally getting some attention from the major news media. A Los Angeles Times story on October 30, 2015 reports on a doctor "convicted of second-degree murder" after multiple patients died of overdose. Though there were allegedly more related deaths, the prosecution was for three particular deaths linked to medication use or misuse. The paper refers to the case as "landmark" and notes that it "was closely watched by medical and legal professionals across the country."

There has been a great deal of discussion in LinkedIn, at conferences, and in blog posts about prescription medication overdose. There is also an interesting and disturbing corollary of increased Heroin use, addiction, and deaths, which some blame in part on their contention that prescription opiods are a gateway drug leading to Heroin use

It is troubling in these conversations when some question whether opiods are that big a deal. Nationally known blogger Mark Pew has heard some of that feedback. He had a recent article on The 5mg Curl that describes some statistics with which it is hard to argue. People are dying. The Los Angeles Times notes that "prescription overdoses kill more people than heroin and cocaine." Americans are consuming mind-boggling quantities of opiods. Obviously, there are valid uses for pain relieving medications. But it appears that there may also be some less-than-valid uses, leading to misuses abuses.

This prosecution is not about opiods, however, but about a drug called Xanax. It is a benzodiazepine. According to Narconon, it is a medication that is abused by hundreds of thousands. Narconon's website notes that people commonly "mix Xanax abuse with the use of other drugs," including "alcohol, opiates, marijuana or cocaine." This statement illustrates one of the problems that bears noting, people are mixing medication prescribed by physicians with street drugs.

Back to Dr. Tseng as reported in the Los Angeles Times. The Times reports that Dr. Tseng is "the first doctor convicted of murder in the United States for recklessly prescribing drugs to patients." She was also convicted of "more than a dozen illegal prescribing counts." A jury "deliberated for two weeks before reaching" decisions regarding the charges. The prosecutor, John Niedermann spoke to the press after the verdict and explained that being a physician is "no shield.” He accused Dr. Tseng of providing drugs in a manner that essentially "shoved them over that cliff."

The examples in the story are interesting. She was charged with prescribing for undercover officers, who "told her about their drug addictions." She was accused of writing a man scripts for the purpose of enhancing his wife's access to medications. Prosecutors claimed that some of her patients had been "charged with dealing drugs," and "two others admitted dealing drugs prescribed by Dr. Tseng." It appears that there were signs of potential problems that might have caused the doctor to reassess in at least some instances?

The enhancement of the man's wife's access is worthy of note. There is at least a perception that "diversion" is a significant problem with many prescription drugs. That is, some pill is prescribed to one person, but instead of being taken that pill is stolen or sold and ends up taken by someone totally unintended. There are some catchy public service television advertisements right now where the person removing the pills from the medicine cabinet is not the person reflected in the cabinet mirror. It is a recognized issue that is important for anyone possessing medication.

The story notes some tendency to blame the patient. After all, those people put the pills in their mouth. Dr. Tseng's mother claimed that the doctor was "deceived by drug-seeking patients." Dr. Tseng's attorney blamed circumstances, noting the doctor "got in over her head.” She claimed that this situation might be appropriate for medical malpractice, but reiterated Dr. Tseng "did not murder people.”

It seems obvious that patients bear some responsibility. Those who have prescriptions need to follow directions for their treatment. Anyone with possession of medications has an obligation to keep them away from children and others who might misuse them. Certainly, there is a shared responsibility. This prosecution, however, establishes that it is a responsibility for which the physician will have significant liability.

According to Dr. Tseng's attorney, this prosecution is having a chilling effect on doctors and their prescription practices. She said that "she has received several calls from cancer patients and others with terminal illnesses who claim the prosecution of doctors like Tseng has led other physicians to limit the amount of powerful painkillers they prescribe, even to those who have a medical need for them."

There are people who need medication to deal with various symptoms and conditions. It is therefore unlikely that prescription drugs will cease to be part of our medical system. Are there reasonable solutions to combat the problems with inappropriate use? Are we doing all that we can to make sure that prescription medications are being used appropriately? We are likely not. There is a good argument for Prescription Drug Monitoring Programs like KASPER and E-Force. They are a start.

Some have recently suggested that the effectiveness of these databases would be enhanced if claims adjusters had access to them. It takes time to search these, and to attempt to monitor the volume of medications any patient is receiving. Certainly, that may deter some physicians from using these databases each time a script is written. It seems adjuster access adds a second layer of potential detection of overuse or misuse. While there may be reasons not to afford such access, such as patient privacy, it seems like an idea that bears discussion in the face of this epidemic.

There will be people who are not responsible with their prescriptions, just as there will be people who are not responsible with their cars. People are not perfect. Physicians cannot solely prevent misuse and abuse, but they will be on the front line of whatever efforts we can make to decrease the number of people dying of medication misuse.

There will almost certainly be malpractice cases, litigation against drug manufacturers, and further efforts at abuse-deterrent formulations. But, will there be more criminal prosecutions of physicians who prescribe these drugs? Should there be?

We may be witnessing a game-changer. Time will tell.

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