Quantity/Frequency of Opiate Prescribing Has Limitations
I received an unusual telephone call yesterday from the office of a military JG yesterday with an all too frequent inquiry. Apparently one of the doctors at her installation had taken a recent Oldwell Consulting’s opiate compliance course, and had referred her to us.
She described piecemeal a scenario where the doctor 1) prescribed 30 Percocet 10 mg for a surgical procedure 2) prescribed 30 diazepam (Valium) 10mg TID with 2 refills for “TMD”, and 3) prescribed 28 alprazolam (Xanax) 1 mg tablets for root canal therapy preoperatively and subsequently provided a refill authorization for same – for the same patient.
The military JG officer then asked me “Do you think this is too much”?
The first instance – while certainly on the upper limit – 30 Percocet 10 mg – wouldn’t necessarily be considered “too much”, but the other two I felt definitely raised a red flag. In the second instance of the diazepam prescription there are 2 issues. First, though diazepam has properties of muscle relaxation, it would seem inappropriate to prescribe for pure temporo-mandibular dysfunction – it would be more appropriate for myofacial pain dysfunction (MPD). Either both diagnoses were bundled into the moniker “TMD” or that diagnosis was in error and so would the treatment.
Secondarily, there are various approaches to treat MPD medically using benzodiazepines. A 10 day supply (#30 TID) of diazepam would not necessarily be too unusual though one might argue again the quantity and duration of treatment is to the upper limits of routine. However, to supply this prescription with 2 PRN refills, in my honest opinion, is out of order. If the medical approach in question were not successful within the first 5-10 days, why would one consider it would be effective over a longer period?
In the instance of the third prescription, there are 3 issues. First, the notion of providing a large quantity of another benzodiazepine – alprazolam (Xanax) – preoperatively – is to be discouraged. Secondly, the amount prescribed itself is I believe without question excessive. And thirdly, yet another refill for in the face of apparent limited treatment seems highly unusual – if not even suspect.
Obviously this behavior triggered an internal military investigation. These investigators wanted to know how a professional licensing board might handle such a situation and whether one might investigate. The question is what and who might trigger an investigation? The doctor’s licensing board does not just necessarily know. It requires some sort of trigger or complaint.
It’s not any one particular thing that initiates a trigger – though if a licensee were to prescribe 100 Percocet 10 mg that might definitely raise some eyebrows. It’s the pattern and the practice of a licensees activities that would be initiating factor. There are three potential triggers – a pharmacist, a patient, or an artificial intelligence-driven computing algorithm within a prescription drug monitoring database.
Would this doctor’s activity with regard to this single patient trigger a board inquiry? Maybe not. But, if this doctor were practicing in a community I believe after a period of time there would probably be mounting pressure. Doctors who have heavy handed prescribing behaviors in one setting have the same in others. In other words, if s/he were to treat one patient in this manner, s/he would likely do the same with others. That corpus of controlled substance prescribing history creates a paper trail which ultimately leads right back to the prescriber.
On a more global basis, however, the one major lesson learned from the opiate crisis is that excessive prescribing of opioids or sedatives only means that people other than the patient will most likely be consuming the left-over drugs. Globally, the quantities in question here certainly suggest a pattern and practice of excessive controlled substance prescribing. In that regard, therefore, all of the quantities could be considered excessive.
Finally, in this instance, other questions might be raised. Was the doctor was really treating an underlying organic anxiety disorder and thus engaging in the practice of medicine without a license? Or even worse, was the doctor engaged in fraudulent scheme of controlled substance diversion for his own consumption or for financial gain? At the very least, prescribing large quantities of benzodiazepines prior to procedures is literally screaming for diversion. All of these questions, I believe, might be fodder for the licensee to answer if the activities in question were to be exposed to the investigative eyes of a professional licensing board.
We admonish dentists to prescribe appropriately and responsibly. The management of chronic pain or psychiatric disorders are NOT the domain of dentists practicing with a dental license alone. Accordingly the quantities of controlled substances prescribed should reflect the appropriate duration of care within the confines of well understood pathophysiologic processes. Our state mandated opiate compliance courses teach our participants these principles.