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In July 2011, Florida enacted sweeping new restrictions that aim to stop or at least dramatically reduce the flow of narcotics from the state’s many “pill mills.” The crackdown has many regulatory and law enforcement agencies concerned that operators of these clinics will attempt to shift their illegal and medically unacceptable practices to other states. The North Carolina Medical Board considers excessive and inappropriate prescribing of controlled substances among its most pressing patient safety and public health concerns. It will not tolerate the patterns of practice typically associated with illegal pill mills and will act swiftly upon any information that such activity is taking place in North Carolina.
This article will provide a brief overview of the problems associated with prescription drug misuse, review the characteristics of pain management clinics often referred to as pill mills and, finally, provide treating practitioners with guidance on spotting “red flags” that may signal drug seeking behavior and/or possible drug abuse/addiction in patients. Prescribers can protect themselves by becoming educated about appropriate standards of care and best practices in pain management.
OVERVIEW OF THE PROBLEM
Each day throughout the US about 75 people die and 2,000 people are treated in an emergency department due to unintentional poisoning. Between 85 and 95 percent of poisoning deaths result from prescription drug misuse. According to the latest data from the NC Center for Health Statistics, unintentional overdoses of prescription medications account for almost three deaths a day in North Carolina. The U.S. Centers for Disease Control and Prevention
(CDC) reports that the increase in deaths from drug overdose is a direct result of increasing abuse and misuse of prescription opioids and other controlled substances.
This increase in some states is directly related to the abundant supply of narcotic medications available due to malicious, illegal and excessive prescribing by individual physicians operating out of what have been termed pill mill pain management clinics. For example, recently a Florida physician was arrested and his medical license summarily suspended. From January through August 2011, this physician reportedly prescribed 250,000 oxycodone pills to his patients. By comparison, in all of California just 300,000 pills were prescribed in the last six months of 2010. The federal government has stepped up law enforcement actions against physicians and others who prescribe excessively and inappropriately. Public policy changes, such as the new law enacted in Florida, are another way of addressing the issue.
Medical regulators in other states know that operators of Florida’s many pill mills won’t simply close their doors. Rather, some are concerned that dangerous and illegal prescribing practices may migrate to other states. A recent article in the Georgia Composite Medical Board’s newsletter, prepared by Adrienne Baker and Jeffrey Lane, outlined certain characteristics associated with these pill mill operations that are not typically found within a legitimate pain management practice. We have shared their list here in order to educate prescribers in North Carolina. Licensees should avoid associating themselves with any practice or clinic with some or all of the following characteristics:
• The physician has minimal to no training in pain management.
• A cursory or no patient exam performed.
• Large volume of patients seen daily (100+).
• Patients drive long distances, often from other states. In many cases patients carpool.
• Clinics place advertisements for pain management physicians in small papers or craigslist.com Employer is a non-physician owned staffing company and work is part time. Clinic owners are not healthcare providers, have no medical training, may be from out of state, and attempt to convince the physician the clinic is operating legally.
• Clinic is run on a cash only basis.
• Similar prescription “cocktail” for each patient.
• Drugs are dispensed onsite (patient pays for office visit then pays for the drugs).
• Security guards are employed by the clinic.
• All patients receive an identical diagnostic work-up or are referred to the same MRI imaging facility.
SPOTTING “DRUG SEEKERS” AND MISUSE
The NCMB often hears that licensees are hesitant or unwilling to prescribe controlled substances because they fear they will be subject to public action by the Board. It’s important to understand what practices are likely
to bring a prescriber to the NCMB’s attention. Often prescribers who come under Board scrutiny have overlooked red flags that should have indicated the possibility of diversion, abuse or misuse. While the presence of “red flags” does not necessarily mean that the patient is “drug seeking” the presence of some or all of the following circumstances should raise the prescribers index of suspicion:
• The patient is from out of state.
• The patient requests a specific drug and states that alternative medications do not work.
• The patient says his or her previous physician closed their practice.
• Prior treatment records cannot be obtained.
• The patient claims he or she cannot afford indicated or appropriate diagnostic testing.
• The patient presents to the appointappointment
with an MRI.
• The patient presents to the appointment with his or her pharmacy profile showing specific drugs they want prescribed.
• Several patients arrive by carpool.
• The patient tests positive for illegal drugs.
• Drug screen reveals no prescribed medication in the patient’s system.
• The patient recites textbook symptoms.
• The patient pays in cash only and has no insurance.
• The patient calls for early refills and prescriptions or regularly reports that medications are lost or stolen.
• The patient’s pain level remains the same over several subsequent visits.
• The patient is noncompliant with the physician’s treatment plan.
The Board recognizes that quality medical care includes the appropriate, effective treatment of chronic pain and supports patients’ rights to such care. The Board further recognizes that prescribing controlled substances over the long term may be an essential part of an appropriate treatment program. However licensees who inappropriately or excessively prescribe opioids and other controlled substances remain an enduring problem. Once again, North
Carolina will not tolerate illegitimate pain management practice as described in this article.
ARE YOU PRESCRIBING BLIND?
The NC Controlled Substance Reporting System (CSRS) is a database of all controlled substance prescriptions dispensed in outpatient pharmacies in North Carolina. This resource can help a practitioner avoid prescribing to a patient who may be receiving controlled substances from multiple sources. For more information on the CSRS, or to download an application for access, visit: http://www.ncdhhs.gov/MHDDSAS/controlledsubstance/
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