One of my best friends is a doctor who is being accused by the medical
board of overprescribing pain medication for a patient with
fibromyalgia. The patient has stabilized at a rather high 120 mg dose
of OxyContin (oxycodone). Since the charges have been leveled at the
doctor, the patient has been treated by a new doctor who has agreed
with the diagnosis and maintained the same prescribed level. An
independent pain specialist evaluated the patient, agreed with the
diagnosis, and supported the prescribing of Oxycontin except that the
dosage might be 20 to 40 mg too high. (The specialist only saw that
patient once.)

The question is, is 120 mg of OxyContin (oxycodone) or similar pain
medication for treatment of fibromyalgia considered overprescribing by
the medical community?

Note: I am not in the medical field. I ask this question because my
friend is confident in his diagnosis and thinks that he will be
treated fairly by the medical board. Therefore, he is not, in my
opinion, preparing an adequate defense. I am not involved in this
matter in any way. The medical board has a growing reputation in our
community for making examples out of doctors as a result of some
unfavorable media coverage they've received. I would like to present
him with some information that supports his position. Hopefully the
board will be fair to him, but one attorney with whom I've discussed
the situation thinks that they will not be fair. Links to the medical
journal articles would be most helpful.

mehuspon -

You ask if 120 mg of OxyContin (oxycodone) or similar pain medication
for treatment of fibromyalgia is considered overprescribing by the
medical community?

This is a very difficult question to answer since prescribing pain
medication is much more of an art than a science.  There are many
factors that must be taken into account, all of which are more
important than the actual disease the patient is suffering (in this
case, fibromyalgia).  For instance, it is more important to determine
the level of pain experienced by the patient and to determine if the
patient has any opiod tolerance.  A good physician will utilize a well
validated pain scale (see below for examples) at each visit to
document and provide support for the current dosage of pain
medication.  Examples of opiod tolerance include heroin addiction or
methadone maintenance.

You fail to mention if the prescribed dosage is 120 mg daily or 120 mg
twice daily (240 mg daily).  In either case, both of these dosages are
within the dosage parameters of the OxyContin package insert. However,
once you start prescribing more than 160 mg daily, you begin to fall
on the very high end of the spectrum.  As a matter of fact, the
following statement about these high dosages (160 mg or greater) is
included in the package insert:

"Special Instructions for OxyContin® 80 mg and 160 mg Tablets (For use
in opioid-tolerant patients only):  OxyContin® 80 mg and 160 mg
Tablets are for use only in opioid-tolerant patients requiring daily
oxycodone equivalent dosages of 160 mg or more for the 80 mg tablet
and 320 mg or more for the 160 mg tablet. Care should be taken in the
prescribing of these tablet strengths. Patients should be instructed
against use by individuals other than the patient for whom it was
prescribed, as such inappropriate use may have severe medical
consequences, including death."

If the patient in question did in fact demonstrate opiod tolerance and
the physician properly documented the patient's pain medication needs
and requirements, it seems that these prescribed dosages may have been
appropriate in this setting.  Many physicians, however, would probably
refer this patient to a pain management specialist to ensure the pain
is being managed appropriately.  Again, pain management is a tricky
business, and this is why we have pain management specialists.

Regarding the charges being brought by the medical board, it seems
unlikely (although not impossible) that your friend's prescribing
practices would be questioned based on this one incident.  Perhaps
your friend has demonstated similar patterns of opiod prescribing
practices in the past; and a demonstrated pattern of poor prescribing
practices may be why he is under investigation.  Regardless, it will
be up to the medical board to carefully review the patient records to
determine if any wrong-doing has occured.

At the Veteran's Affairs website, you can find a very comprehensive
clinical practice guideline regarding opiod therapy for chronic pain:
http://www.oqp.med.va.gov/cpg/cot/cot_cpg/frameset.htm
PDF Version:  http://www.oqp.med.va.gov/cpg/cot/G/OT_CPG-v1.0.pdf

It would be very unlikely for the medical board to make a ruling
against your friend if he documented and provided care according to
this governmental guideline.  Perhaps he should read this guideline
before he meets with the board.

Examples of well validated pain scales:
http://www.ama-cmeonline.com/pain_mgmt/module01/05eval/05_01.htm
http://www.ama-cmeonline.com/pain_mgmt/module01/05eval/04_01.htm

Hope that sheds some light on his situation.  Perhaps some of the
google researchers can provide additional information.

-d

njbagel, thanks for your input. I am confident that he is not abusing
his privileges. He has been very open and forthcoming about this
matter. Our state's board has been catching a lot of media attention
for sitting on their hands, so they are aggressively pursuing any
cases on the table right now. That does not necessarily mean that they
are going to throw logic and reason out the window, but who knows?

As I age and face the increasing possibility of needing pain
management, I shudder to think of the chilling effect that these witch
hunts may have on our ability as patients to be treated for chronic
pain. With a little luck, I will never be in that position, but, of
course, we never know.

Considering how much his income has been limited because of Medicare
reimbursement, how much his malpractice insurance costs are, and how
his hopefully validated judgment is being questioned, the practice of
medicine is losing some of its appeal. This guy is a great doctor and
is quite regularly called in on consults because of his diagnostic
ability. While I am not aware of any, I'm sure he has made mistakes,
just as we all have; but I could understand it if he told them to take
their license and shove it. He would make an excellent plaintiff's
lawyer in medical malpractice cases.

Again, thanks for your input. I will pass the information along to him.