The Seven Deadly Sins: Overprescribing

Excessive prescribing is another facet of gluttony, although the impetus for the physician is usually a different sin: greed. In the early 90s, [The Medical Board] . . .  revoked the licenses of physicians who sold prescriptions for Dilaudid for distribution on the street. Today, Oxycontin is the analgesic du jour, and was the nemesis of a physician whose license was recently revoked for selling enormous quantities to a motorcycle gang. Then there are the run-of-the-mill-pill cases: physicians who provide prescriptions for Vicodin, or whatever else the patient requests, without an appropriate prior examination and a medical indication. Los Angeles is particularly rife with drug cases and the occasional high-profile case involving excessive/inappropriate prescribing to celebrities. The tragic aspect of these, and many of the complaints we receive, is that often the physicians do not come to the board’s attention until someone has overdosed. 

Frequently, a complaint is initiated because Dr. X is prescribing huge amounts of Norco and Soma to the complainant’s spouse. The complainant is worried – angry – frustrated because their loved one just got out of rehab. The complainant called Dr. X to implore him to stop writing prescriptions, especially the ones from which the loved one was just detoxified, and Dr. X will not stop. Other times, the complainant is the parent of a child who has overdosed. The parent finds their dead child among hundreds of bottles of pills. Sometimes the complainant is another law enforcement officer who pulls someone over and finds scores of pill bottles in their vehicle.

Over prescribing cases can be very complex to investigate. This is because investigators must determine whether the patient is suffering from a legitimate pain condition and is legitimately receiving large quantities of narcotics, or whether the patient is merely drug seeking or diverting drugs for sale on the street. Sometimes, to further complicate matters, a patient may be both.

The discernment process ordinarily begins with a review of a Controlled Substances Utilization Review (CURES) report for both the physician and the patient. The report is called a Patient Activity Report (PAR) and is used to analyze patterns of over prescribing. The PAR form can be downloaded from the board’s Web site. What kinds of things pique our curiosity? The quantity of a particular drug is just one piece of information. There are circumstances where a huge amount of narcotics may be perfectly appropriate. So, we look to see how many doctors the patient is visiting. Is the patient “doctor shopping” and going to different pharmacies to avoid detection? Does the patient live a ridiculously long way from the physician’s practice? None of these factors, in and of themselves, may be problematic. Our index of suspicion rises, when we see a multitude of these patterns. Please see page 12 for a list of potential indicators that may suggest a patient is using prescriptions inappropriately. This is an excerpt from a Department of Justice brochure entitled, Guidelines for Combating Prescription Drug Abuse and Fraud.

An investigator may initiate surveillance or undertake an undercover operation. If the undercover operation proves fruitful, then a search warrant may be considered. Prescribing without a legitimate medical purpose is a both an administrative and criminal offense.

But, before you are incapacitated with concern that board investigators may be lurking in your waiting rooms, please understand that the office waiting areas, where search warrants are executed, often look like a Grateful Dead reunion. By the time a warrant is sought, usually one or two operatives have visited the clinic on several occasions and received controlled substances for absolutely no legitimate medical reason.

MBC investigators know that most patients receiving narcotic medications are receiving them in a perfectly legitimate way. MBC investigators also have no interest in discouraging physicians from prescribing narcotic analgesics to patients suffering from a medical condition causing pain; that is why so much time is spent distinguishing the legitimate pain management practice from the pharmaceutical drug peddler. Investigators are mandated to receive specialized training in pain management cases to make certain physicians who follow the intractable pain guidelines (Business and Professions Code section 2241.5) are not disciplined for over prescribing. Also unique to these cases is that once investigators obtain medical records, interview all of the relevant parties, and interview the physician, if it appears there may be a violation of law, the case must be reviewed by two experts: one whose specialty is pain management, and one whose specialty is that of the prescribing physician. That is important for you to know: we investigators do not decide whether the standard of care has been met. Your peers make that determination. Our job is to provide the board’s peer reviewers with the best information possible from which to render an unbiased and thorough opinion.

The Medical Board’s Web site (www.mbc.ca.gov) is an information glutton’s dream. You can find guidelines and laws regarding pain management, prescribing, ordering CURES reports and the Diversion Program (among many other subject matters). This is an excellent resource to familiarize yourself with these and other issues, and there are numerous resources available to you online, if you have concerns about a patient, a colleague, or your own situation.

Read this entire series at the Medical Board of California.

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