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Utah Physicians Licensing Board
COMMENTARIES
Prescribing Controlled Substances for Cancer Pain:
Position Paper of the Utah Division of
Occupational and Professional Licensing
David E. Robinson
The Division of Occupational and Professional Licensing of the Utah State Department of Commerce is the agency charged with the responsibility of licensing and regulating the practice of various practitioners who have the right to dispense, administer, and prescribe controlled substances as they are defined by federal and state law. The Division is also responsible for the administration and enforcement of the Utah Controlled Substances Act as it relates to the regulated professions. The Division has the authority, upon finding of cause, to revoke, suspend, restrict, or place on probation both the professional license and the Utah controlled substance license issued to an individual.
There is within the Division a professional licensing board for each of the regulated professions. Each board is generally made up of four to six professionals and one member representing the general public. The boards are created to advise the Division and recommend appropriate sanctions in cases of unprofessional or unlawful conduct by a licensee.
Regulation of the licensed professions is approached by the Division from the position that the licensees are usually competent in the practice of their professions and justified in their conduct. It is inappropriate, except on rare occasions upon a showing of good cause, for the Division to insert itself into the near sacred relationship which must exist between a licensed health care professional and his patient. That relationship must be founded in the competence and wisdom of the practitioner coupled with the trust and cooperation of the patient. The unnecessary and unwise intrusion into that relationship by the "regulator" is the classic representation of abusive government acting at its worst.
In its effort to fulfill its statutory responsibilities under the professional licensing acts and the Utah Controlled Substance Act, the Division both receives complaints and proactively seeks information regarding uses of controlled substances. After identifying prescribing patterns involving high uses of controlled substances, and/or repeated and frequent prescriptions over a period of time, our experience has shown in well over 90% of the cases that one of the following is occurring:
1. an honest and well intentioned practitioner is being duped by a drug seeking person; or
2. a patient in need is appropriately receiving high doses of a controlled substance to handle intractable pain associated with a terminal illness or other serious condition.
In the event of either of the above, it is clear from our experience that a courteous call upon the practitioner with a request for an explanation usually determines that the practitioner has been an innocent victim, or the practitioner is properly treating a patient's need. When the circumstances involve a drug seeking individual, the practitioner is grateful for the information indicative of the extent of the patient use, the fact that the patient may be seeing other practitioners for the same purpose, and the article used by the patient to receive controlled drugs. The dialogue results in an educational experience for the practitioner and a positive interchange with the regulatory representative. In those cases involving proper treatment for pain, there results again a positive experience between the practitioner and the regulatory representative. It is rare that the practitioner expresses or displays any resentment over a courteous and professional inquiry.
On rare occasions, inquiry determines inappropriate prescribing of controlled substances. Over 90% of those rare cases involve one of the following:
1. inappropriate prescribing by a practitioner for "profit," with profit found to be money, sexual favors, splitting use of the drugs with the patient, or other creative reasons which are usually unlawful as well as unprofessional; or
2. the physician is well intentioned; but, he is simply not adequately prepared to handle the total circumstances with which he is presented and his prescribing of controlled substances is inappropriate.
With respect to the first circumstance, the Division proceeds with appropriate action against the license(s) of the practitioner and considers filing of criminal charges when appropriate.
On occurrence of the second circumstance, a relatively infrequent occurrence, the Division considers the appropriate course of action to be education. We are not dealing with an intentional inappropriate act or a practitioner of poor character or ability. It is our position that such a contact by the regulator's representative with the practitioner should result in a positive experience when handled in a courteous, caring, and professional manner.
Utah has considered the adoption of a triplicate prescription program noting that per capita consumption of certain controlled drugs has been ranked very high nationally. Those drugs have typically been amphetamine, methamphetamine, methylphenidate, cocaine, hydrocodone, opium tincture, and sufentanil. Upon a belief that a triplicate prescription program unnecessarily intrudes into the conscious process of a practitioner's decisions with respect to treatment of a patient, the State of Utah has rejected the triplicate program as the best option. Alternatively the course being studied is the adoption of a program which will directly "read" the computers of all retail pharmacies and transfer information regarding controlled substances dispensed on prescription into a Division data base. The same information available through a triplicate program will be available to the Division much more quickly and without the need to enter data a second time. Most importantly, the information will be available without imposing upon the physician the conscious reminder that the regulator is looking at his prescribing of a controlled substance for that patient. The influence of the regulator is left, if ever to be exposed, to a private, courteous, and professional interchange between the practitioner and regulator's representative when such appears necessary.
Old expectations die hard and practitioners' fear of regulators watching over their shoulders remains active in the minds of too many practitioners. An effective regulating agency known for its understanding of the professions which it regulates, and a policy of fairness, best serves the interest of the public it is directed to serve. Such a policy may result in a failure to administratively handle or criminally prosecute an offending practitioner as quickly as it otherwise might. Such a policy will probably prevent, however, the inappropriate intervention of that regulator in that near sacred relationship which must exist between a competent and dedicated practitioner and his patient in need. That inappropriate intervention would be the greater wrong.