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Pain Management Claim Analysis
Printable Version of this Article
Scenario
This patient had a history of an autoimmune disease with associated joint pain and severe low back pain as a result of an injury sustained during a motor vehicle accident. Over the course of three years the Primary Care Physician (PCP) prescribed various combinations of narcotics and other pain medications. During several office visits the PCP documented the recommendation that the patient consult a pain management specialist. The patient was non-adherent with this recommendation. The PCP continued to provide prescription refills for narcotics without a required office visit. At one point medical records reflect that the patient experienced “altered mental status” and was brought by police to the local emergency department after he was found wandering in a local park. Several months later the patient was found dead in his home of an overdose of prescription and illicit drugs.
Discussion Points:
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The allegations included improper medication regimen management in that inappropriate combinations of narcotics were prescribed. Physicians should exercise caution when prescribing medications which may be outside their area of expertise and may be more appropriately managed by a specialist.
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Although this physician was not a pain management specialist, the court considered standards of care that relate to treating patients with chronic pain as being appropriate. As a result, it was determined there was failure to adhere strictly to standard pain management practices including:
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Periodic lab testing for illicit and prescription drug levels.
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Physical, mental, and objective pain assessments on a routine basis.
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Patient education and understanding of risks.
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Patient agreement or contract as to the treatment plan (strict prescription refill requirements such as requiring an office visit and limitation on the number of pills prescribed at one time).
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Consideration of other pain management modalities such as counseling to assist the patient in coping with chronic pain and addiction.
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Liability was attributed to the PCP because the medical record failed to document the discussion of the care plan, patient non-adherence to this plan, an explanation of the risks involved in non-adherence, and patient understanding of these issues. There was no documentation that the PCP took reasonable efforts to ensure the patient understood the risks of non-adherence with recommendations. The physician also failed to use a format (i.e., problem lists or integrated summaries, medication renewal flowsheets) which promoted easy identification of significant past clinical information. Tools such as these make it easier to find key information, especially when review of the chart (prior to prescription renewal) is only cursory. In this case, the PCP could have identified that the patient was not evaluated in the office for some time and, therefore, declined to renew prescriptions over the phone.
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