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Curtailing prescription opioids puts doctors at risk from violent patients

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As doctors treating workers compensation claimants curtail prescribing opioid pain medications, some physicians are facing more threats from patients addicted to or illegally selling the drugs.

The problem usually occurs with older, legacy workers comp claims. In these cases, addictive opioid narcotics have been prescribed long term, without the medication compliance monitoring and patient education in place when recently injured claimants are prescribed the pain medications, doctors and workers comp experts say.

The hostilities against doctors trying to wean patients off the prescriptions or stop them from illegally diverting the drugs for profit range from death threats to property damage. Often they are perpetuated by patients who have come to expect they will continue receiving the painkillers, experts say.

Patients with minds warped by drug use and financially dependent on selling prescriptions have threatened to report doctors to state licensing boards for alleged sexual improprieties, said Dr. Hans C. Hansen, president of the American Society of Interventional Pain Physicians who treats workers comp patients and others in Conover, N.C.

“It's more and more of a concern,” Dr. Hansen said. “They make serious threats. We know examples where tires have been slashed, cars have been keyed. In my case, a patient tried to throw a chair through a window.”

Hostilities against doctors are common, with opioids becoming a public health concern and workers comp payers trying to reduce the inappropriate use or overuse of prescription narcotics, experts said. Often the threatening behavior occurs when a pain management specialist inherits a patient from another doctor who has prescribed the opioids over an extended period with few questions asked.

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Stiffer enforcement and recent arrests of doctors supplying the drugs through “pill mill'' operations has worsened the problem for physicians following strict prescription guidelines, said Dr. Sanford Silverman, a pain treatment specialist in Pompano Beach, Fla.

He said he warns new patients and workers comp claims managers that he does not prescribe narcotics on a patient's first visit.

“No one has ever told me "I am going to kill you or your family if you don't give me this,' but I have been yelled at and screamed at,'' Dr. Silverman said. “I think it is getting worse. We have seen very explosive behavior from people who don't get what they want.''

Increasingly, more doctors attempting to help patients suffering from pain have learned about the dangers opioid medications can pose to patients' health. Often they have adopted applied protocols or treatment guidelines that are considered best practices.

These protocols include: urine screening to ensure patients are consuming drugs as prescribed and are not mixing them with illegal drugs; setting goals for medical and functional improvements patients are expected to achieve, with continued use of opioids contingent on meeting the goals; and using written agreements to document the patient's treatment plan and improvement expectations.

Increased media reports about the dangers of opioids, growing awareness on the part of patients and health care providers about the narcotic painkillers, and the implementation of the best practice guidelines are leading to fewer cases of threatening patient behavior, said Dr. Robert L. Hall, medical director for Progressive Medical Inc., a Westerville, Ohio-based pharmacy benefit manager.

“The key, though, is in patient selection, early education and ongoing communication” with the patient, Dr. Hall said.

Dr. Teresa Bartlett, Troy, Mich.-based medical director for Sedgwick Claims Management Services Inc., said she hears about threats against physicians, including threats against their lives, about once a week.

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This comes as Sedgwick, a third-party administrator, increases efforts to address aging workers comp claims that show signs of inappropriate opioid prescribing.

“Physicians are trying to use all the best practices and adopt protocols for chronic pain then they find someone's drug screen is negative,” Dr. Bartlett said. “They are not even taking the medication or they are taking illicit drugs with the medication. Then the doctor does the right thing. They say, "I will still be your doctor and help you through this, but I can no longer prescribe for you or I am going to begin weaning you off immediately.' And then when there is a diversion problem, the injured worker gets very angry and it leads to threats.”

The frequency with which she is seeing such cases shows the need for workers comp payers to scrutinize their claims through data mining for signs of diversion.

Dr. Bartlett described the case of an elderly claimant whose body cannot metabolize the amount of opioid narcotics prescribed for her. Her sons regularly accompanied her to doctor's appointments and police were called when the sons threatened the doctor who sought to cease the prescriptions.

While some doctors say they encounter no or few such cases, Dr. Hansen said that for those physicians with lengthy experience treating patients with chronic pain, “it's a very real thing.”

“Sometimes the patients are not going to get the candy they want. They are going to get what they need, not what they want and that leads to hostility,” Dr. Hansen said.