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Seminar offered tips for controlled substance prescribers
The Legalities of Controlled Substance Prescribing," seminar attracted a full house to the Fishers Conference Center. The Oct. 10 ISMA CME was prompted by headlines about two Indiana physicians now in prison for improperly prescribing controlled substances.
"It's important for physicians to recognize patients who are taking advantage of them and protect themselves," said Julie Reed, ISMA legal counsel. "This program helped physicians do that, and
also served as a reminder that physicians who are oblivious, careless or motivated by greed can pay
a heavy price."
Some information from the speakers is provided here. Learn more about INSPECT, the state's controlled substance prescription monitoring system, on page 4 and purchase a DVD of the entire
CME session for $25 by calling the ISMA.
Tips from federal agents
Josh Minkler, assistant U.S. attorney for the Southern District of Indiana, Drug Unit, said physicians
are prosecuted for "prescribing outside the bounds of professional practice." He explained that prosecutors seeking to convict must prove a physician:
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Distributed, dispensed or wrote prescriptions for controlled substances
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Acted knowingly or intentionally (not a mistake)
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Dispensed or wrote prescriptions not for a legitimate medical purpose or outside the bounds
of medicine, further described as times when a doctor
a. Knew the patient had no legitimate need for the drug
b. Knew the patient was abusing or not using the drug for legitimate purposes
c. Knew the patient was selling the drug
d. Took deliberate steps NOT to know a., b. or c.
Winfield Ong, assistant U.S. attorney for the Southern District of Indiana, Fraud Unit, said his staff
must answer these question when investigating prescribing practices:
• Was there a thorough exam of the patient?
• What is the diagnosis?
• Is there a treatment and/or drug plan?
• Is the plan being followed?
• Is there documentation in the file?
• Is follow-up or drug screening being done?
Ong said be suspicious when patients ask for a drug by name, are vague about their pain, travel
long distances for care, or refuse diagnostic or follow-up testing. He also said physicians need to
hold patients to their treatment plan and, if they diverge, document the reasons.
Madeline Kuzma, Diversion Investigator with Indianapolis office of the Drug Enforcement
Administration (DEA), focused on record keeping to prevent diversion. She advised physicians to inventory initially and biennially. Dispensing records, which should be maintained for two years,
should include the drug, amount, date, name and address of patient, and name of dispenser.
She noted the DEA Practitioner's Manual is available online and said physicians:
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Must sign prescriptions themselves and cannot use electronic signatures or ink stamps
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Should lock up their prescription pads
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Should not take drugs back from patients
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Should not fear a "witch hunt" since the DEA took action against only 0.07 percent of allregistered physicians in 2006
Cautions from the state
Terry Richmond, from the Office of the Indiana Attorney General, stated physicians become the
subject of investigations generally because they are:
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Too busy to assess patients and document
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Influenced by patient demands
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Inattentive to patient and office staff
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Uninformed about best prescribing practices and patient response to medication
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Over-delegating prescribing and record-keeping
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Trying to do a friend or relative a favor
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Using shortcuts
An addiction medicine physician speaks
"Addiction is a brain disease," began Randy Stevens, M.D., chair of the ISMA Commission on
Physician Assistance, who is certified by the American Society of Addiction Medicine. He suggested physicians review the Federation of State Medical Boards guidelines.
Dr. Stevens reminded physicians to monitor patients carefully and regularly and consider drug screening. He noted much abuse occurs from drug sharing between friends and family. He also
shared a copy of the "Medication Agreement" he uses to set rules when prescribing potentially addictive drugs.
A defensive perspective
J. Richard Kiefer, an attorney from Bingham McHale LLP, stressed the importance of having a compliance program. He suggested establishing office protocol for a potential government
investigation and training "contact" staff so they know what to say and not say.
"Establish your ethics and code of conduct," he said, "and make it clear to staff." He advised
conducting internal audits. Also, if you receive information that a patient is selling or abusing
medication, do not ignore it.
Finally, Kiefer urged physicians contacted by the government to avoid obstruction of justice by not destroying or altering documents or filling holes in charts. Ending the session, he revealed the
biggest problem in defending physicians: lack of documentation.
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