Physician fears concerning controlled substance prescribing called overblown

OB/GYN News, April 15, 2003 by Joyce Frieden

NEW YORK -- Many doctors are afraid that they will get into trouble with the Drug Enforcement Administration every time they write a prescription for a controlled substance, but those fears are overblown, according to one DEA official.

"We'll only come see you if something happens that distinguishes you--primarily for us, it's complaints. We'll go see a physician if there's a complaint [against him or her]," Laura Nagel, the DEA's deputy assistant administrator in its Office of Diversion Control, said at a meeting sponsored by the National Center on Addiction and Substance Abuse at Columbia University. Only 500 DEA agents nationwide are focusing on prescription drug abuse, compared with the 4,500 agents who are working on issues related to illegal drugs, she said.

Mary Baluss, founder of the Pain Law Initiative, which advocates for better pain management, said some concerns may be justified. "Physicians have been beaten over the head with it," she said. 'There has been intense scrutiny of doctors who are treating people for pain, and maybe not well. We can all agree that medical errors happen across the board, and it's horrible. However, when a doctor is treating pain, whether he or she is doing it correctly, they risk going to prison for 20 years.

And it's not just long-practicing physicians who feel that way "I gave a lecture at Duke [University] about a year ago and finally one of the young residents said, 'If you think for a minute that I've worked this hard to get where I am to risk it by writing prescriptions for chronic pain, you'd better think again.' I think we do a really good job of scaring doctors to death in this country," she added.

Richard Blumenthal, Connecticut attorney general, said doctors should not be afraid that they will be prosecuted for committing an error. "A doctor who, in good faith, makes a mistake is not going to be prosecuted, or at least he shouldn't be," he said.

Although some diversion of controlled substances to the black market may be done by physicians, much of it is done by patients who have somehow gotten hold of the doctor's DEA number or prescribing pad. (See box for information on how to prevent drug diversion by patients.)

One way the diversion situation might be improved is if the DEA worked more closely with individual physicians if a particular patient is suspected of diversion, Ms. Baluss said. "I Would like to see more healthy collaboration. The doctor should not find out that a patient is abusing his trust when [the government] shows up with a subpoena."

RELATED ARTICLE: Halting drug diversion from the office

Physicians can do several things to prevent patients from using their office to obtain and sell controlled substances, according to Dr. J. David Haddox, vice president of health policy at Purdue Pharma L.P., the manufacturer of OxyContin (oxycodone), a frequent target of drug diverters:

* Treat your prescription pad as if it were a checkbook. Keep it locked up when it's not in use.

* Write out the prescription in words. For example, write ten instead of "10," so patients can't easily change "10" to "70."

* Use a tamper-proof prescription pad. Such pads can have several safety features, such as heat-sensitive designs, that make them harder to duplicate. Purdue Pharma gives these pads to physicians.

In California, doctors are required to use pads that make triplicate copies of each prescription for a controlled substance--one for the doctor, one for the pharmacist, and one for the Department of Justice.

* Use a thorough urine drug screen. Many drug screens only test for illegal drugs, but you need more than that if you suspect a patient of diverting prescriptions.

In this particular case, you might want to test to see whether the drug you prescribed is actually in the patient's system.

The California Academy of Family Physicians has published a monograph on urine screening that discusses these considerations in detail. The three authors of the monograph, available online at www.familydocs.org/UDT.pdf, are physician consultants for Purdue Pharma.