Opiods for the treatment of chronic pain: is there a risk to the physician?

            Dr Ashburn writes, in the June 17, 2007 edition of The New York Times Magazine, Tina Rosenberg wrote the cover story entitled "When is a pain doctor a drug pusher? (http://www.nytimes.com/2007/06/17/magazine/17pain-t.html?ex=1185508800&en=96ed7956679244fb&ei=5070) The focus of this article includes a discussion of the upsurge in the use of potent opioids for the treatment of chronic pain.  The article points out that as opioids have become more widely used, so has the investigation and prosecution of some of the physicians who prescribe these drugs.  In addition, several states have developed or are in the process of developing guidelines that place limits on the amounts of opioids that can be prescribed.  A summary of pain management guidelines by state can be found at http://www.fsmb.org/pdf/grpol_pain_management.pdf.  These guidelines often require patients who receive high doses of opioids (as defined by the governmental authority) be seen by a pain expert.

            The article reports on the recent prosecution and conviction of Dr. McIver.  McIver was convicted in federal court of 1 count of conspiracy to distribute controlled substances, 8 counts of distribution of controlled substances, and 1 count of dispensing drugs that resulted in a death of a patient.  He is serving concurrent sentences of 20 years for 1 of these counts and 30 years for another of these counts.  His appeals of the convictions and sentencing have failed.

            Dr. McIver appears to have prescribed very high doses of opioids to some patients.  In addition, he kept very poor records.  One investigator described his records by stating “His patient records were manila envelopes stuffed with receipts.”  In addition, it appears that McIver continued to prescribe potent opioids even when he became concerned that patients were abusing or diverting the opioids he was prescribing.

            Dr. McIver's conviction points out the importance of using common sense when prescribing opioids as a part of patient care.  Model guidelines for the use of opioids for the treatment of chronic pain have been published by the Federation of State Medical Boards of the United States.  A copy of these guidelines can be found at http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf .  However, the big question is when does physician behavior stop being an issue to be addressed by the state medical board and start being a criminal offense?  Clearly, physicians who prescribe opioids need to do so in accordance with current medical practice and must be diligent with their medical records.

            This article raises several issues that anesthesiologists will be dealing with for some time.  How strong are the data supporting the assumption that opioids are beneficial for the long-term treatment of chronic pain?  How well do we understand the risks of harm associated with this practice, which may include fundamental changes in endocrine function, hyperalgesia, changes in sexual function, and addiction, as well as the commonly-described opioid-induced adverse effects?  What is the appropriate role of governmental agencies in establishing rules for medical practice?  Do pain physicians have the interest or resources to be responsible for the care of patients requiring high-dose chronic opioid therapy?  What are the risks to the physician who prescribes opioids, and what measures can reasonably be taken to avoid investigation and possible prosecution for this aspect of medical care?

     Michael Ashburn, M.D. is Director of Pain Medicine and Palliative Care in the Department of Anesthesiology and Critical Care, University of Pennsylvania