Physician and public awareness of issues related to opioid use has skyrocketed over the past several years. Prescription drug abusers outnumber those who use all other "street" drugs except marijuana, and twice as many deaths are caused by prescription opioids than heroin. Every state except Missouri now has a Prescription Drug Monitoring Program (PDMP) that tabulates and distributes data about federally controlled substances that are prescribed and dispensed.

For the conscientious surgeon, it's difficult to imagine how any provider could turn his or her back on the Hippocratic Oath and become an employee of a so-called "pill mill," trading prescriptions for cash. If you're reading this article, the odds are that you are not one of those physicians. So how can you ensure that your usual daily practice avoids accidentally violating the newer, stricter regulations?

For one thing, remember that jotting off scripts for hydrocodone or oxycodone for patients "to have around just in case they need it" is not a good idea.

Take the case of one orthopaedist we will call Dr. Smith, who was quite the opposite of an uncaring physician. Dr. Smith's practice included a number of hospice patients in multiple facilities over a wide geographic region. To facilitate emergency prescriptions when off-site, he would presign some prescriptions for the nurses following his patients to complete as needed, after conferring with him by phone. This well-intentioned move is what landed Dr. Smith in trouble with the state board, which ultimately placed him on probation for a year.

It is also possible to get into trouble with just a few patients, as was the case for Robert C. Turner, MD, a well-respected orthopaedic surgeon who had been practicing for decades. Most of his patients were treated appropriately; however, a few chronic pain patients who were abusing prescription medications added up over time. He continued to treat them with narcotics, including acetaminophen combinations. Dr. Turner had his license suspended for 6 months, which resulted in him losing his job, partners, Drug Enforcement Administration certificate, hospital privileges, and malpractice insurance.

Dr. Turner is one of the fortunate physicians who was able to reestablish a very limited practice afterward, although it was a long and difficult process. He notes there are hundreds of physicians in the same situation who were not trained to screen chronic pain patients for abuse or diversion.

Tips for orthopaedists
Lack of knowledge is not a defense if you violate state or federal regulations. It's entirely possible that your first communication from the state board will not be limited to a warning and may lead to the loss of your license. So how can you adapt your practice to the new laws? Here are some basic tips:

• Know your state's guidelines and follow them. Many states mandate review of the state PDMP site prior to writing a narcotic prescription. For information about the PDMP in your state, visit Brandeis University's PDMP Training and Technical Assistance Center online at http://www.pdmpassist.org/content/state-profiles
• Protect your passwords and prescription pads. To prevent other people from prescribing controlled substances under your name, do not allow others to use your electronic medical record system login and password. Keep prescription pads locked, and never sign blank scripts.
• Document visits, and cite patients' pain issues and exam findings that support the need for potent medications. Avoid cursory exams or electronic visits. Follow up with chronic pain patients appropriately, including with urine/blood tests and state prescription log checks, or refer them to a pain management physician.
• Educate patients on controlling—rather than eliminating—pain. Discuss and document alternatives. Alert patients about state monitoring programs.
• Ensure that patients in pain have access to appropriate medication. Watch for red flags of drug seekers, who are estimated to make up 10 to 15 percent of patients.

Special thanks to Bob Ricchiuto, director, Special Investigative Unit for HealthSpan, and John Burke, commander, Brown County Drug & Major Crimes Task Force, for assisting with this article. Thanks also to Dr. Turner for agreeing to share his story to help his AAOS colleagues.

Laurel Beverley, MD, MPH, is a member of the AAOS Medical Liability Committee. She is employed by the MetroHealth System in Cleveland, Ohio, and can be reached at lbeverley@metrohealth.org

Editor's note: Articles labeled Orthopaedic Risk Manager (ORM) are presented by the Medical Liability Committee under the direction of John P. Lyden, MD, and Michael R. Marks, MD, MBA, ORM co-editors. Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional. Email your comments to feedback-orm@aaos.org or contact this issue's contributors directly.