Recently, the Medical Board of California circulated an open letter, known as a Prescriber Guidance Letter to all practitioners in California who prescribe opiates. The letter was authored by a statewide workgroup on Prescription Opioid Misuse and Overdose Prevention. The workgroup includes the Medical Board of California, the Board of Pharmacy, the California Department of Public Health, the DEA, DMV, California Department of Justice, California Health and Human Services, California Society of Addition Medicine, and California Healthcare Foundation, among others.

The Prescriber Guidance Letter was accompanied by a number of resources for providers facing these situations, including Strategies for High Risk Patients, Medication-Assisted Treatment Certification Programs, Local Addiction Recovery Services Locator, CURES information, Opioid Prescriber Resource Sheet, and Opioid Prescribing Guidelines.

The letter prominently displays the Subtitle “Don’t Fire Your Patients Who May be Over-using Opioids.” This request stands in contrast to most provider risk-avoidance guidance, which would suggest that terminating the patient from the practice is the best way to insulate the provider from regulatory scrutiny. The Medical Board of California Expert Reviewer Guidelines regarding the treatment of pain focus on excessive prescribing concerns; gone are the days of concern for the undertreatment of pain. Many pain contracts, for example, authorize the provider to terminate the patient from the practice for any breach of the agreement, including the patient’s overuse of medications, early filling of prescriptions, and the patient getting medications from other providers. The rapidly evolving and constantly changing regulatory guidelines make it hard for prescribers to stay compliant. In addition, retrospective case reviews can be skewed when viewed through the lens of subsequently-released guidelines.

The Prescriber Guidance Letter acknowledges “providing safe and effective pain management can be challenging.” The authors further recognize the difficulty in weaning patients off of opiate medications. “One of the most difficult situations for prescribers may be how to respond to patients with difficulty decreasing opioid intake or with other possible addiction symptoms.” This recognition of the difficulty in getting patients off opiate medications and the important role physicians will need to play to reach a resolution to this issue serves as a counterpoint to the communications from other agencies, such as the federal Centers for Disease Control, which suggests the opioid epidemic is a “doctor-driven” problem and recommends no more than 3 days of opioid treatment.

Prescribers are surrounded by guidelines from various regulatory bodies, such as the Medical Board of California and the CDC, as well as academic bodies, such as The American Society of Addiction Medicine, regarding the safe and recommended approaches to treating patients with pain. These often-conflicting guidelines can lead to confusion as to the appropriate standard of care.

LESSONS LEARNED

  • California is actively seeking to address the opioid epidemic.
  • Some patients have chronic pain and their opiate medications cannot simply be stopped cold-turkey.
  • Physicians must be an integral part of the solution, rather than abandoning their patients at the first sign of non-compliance.