Physicians Who Prescribe too Many Painkillers Head Back to School to Save Licenses
Investigators at the Vanderbilt University Medical Center created the Center for Professional Health (CPH), which provides a program for health professionals who overprescribe painkillers or other controlled drugs.
The three-day course, "Prescribing Controlled Drugs: Critical Issues and Common Pitfalls," allows participants the opportunity to:
- Vent anger at being accused of wrongdoing.
- Examine the reasons that might underlie their prescribing problems.
- Learn strategies designed to prevent problems in the future.
- Project staff held four pilot sessions of the course, serving 33 physicians.
- After refining the course, they held 16 additional sessions with a total of 113 physicians from 14 states.
- The vast majority of participants had prescribed large quantities of narcotics for back pain, migraine headaches, arthritis, and other "non-malignant" conditions.
- These physicians often had a history of being duped by drug-seeking patients, prescribing for office staff or family members, or not documenting their treatment decisions in patient records.
- The majority were in solo practice in small towns or rural areas, and some had a drug use problem themselves.
The Robert Wood Johnson Foundation (RWJF) supported the project with a grant of $349,970 from 1997 to 2000.
In most states, there are few options for dealing with physicians or dentists who misprescribe, over prescribe, or fail to monitor patients taking drugs that have a high potential for abuse. State medical boards often have no other option but to suspend these professionals' license to practice or to issue them a formal letter of censure. Early intervention is needed to confront those health professionals who are heading for serious trouble, but who do not yet deserve to have their license revoked.
This grant from RWJF supported the creation of CPH at Vanderbilt, which provides early intervention services to health professionals throughout the southeast region of the country. These physicians come to the attention of their state medical boards, which govern physician licensure, as a result of patient complaints, pharmacists' reports, or inquiries from the federal Drug Enforcement Administration.
In its first year, the project held four pilot sessions of the course for 33 physicians who had been referred by authorities in their home states. The course is designed to give participants the opportunity to:
- Vent their anger at being accused of wrongdoing.
- Learn that they are not being singled out by their state medical board.
- Examine the reason or reasons that might underlie their prescribing problems.
- Learn strategies designed to prevent problems in the future.
Each session was limited to 10 to 12 participants in order to create a small-group atmosphere that would encourage openness and honesty. During the course, each physician completed a genogram for his or her own family, which diagrams a family tree, including history of illness and other patterns.
Investigators have noted that many physicians who misprescribe come from a chaotic family background, with alcohol dependence frequent in previous generations. Unlike similar courses offered in other states, the CPH course focuses on changing health professionals' prescribing behavior. Only a relatively small portion is devoted to increasing their knowledge of the pharmacologic properties of these medications.
Based on the participants' feedback, CPH refined the course. Several participants said that they needed more ways to counsel various types of patients, so CPH put greater emphasis on role-playing in order to teach participants different communication strategies. Project staff also added several practice-management tools to the course material because participants said they needed clinically relevant material to support their counseling and documentation needs. (This included a training document for office staff and a prescription "contract" for patients to sign.)
Project staff marketed the course to all state medical boards and physician assistance programs (which work with physicians in personal or professional crises) using mailings, a brochure, and announcements in professional publications and at national meetings.
The project also received support estimated at $70,000 from Vanderbilt and office space and equipment from the RWJF national program office for Fighting Back®, a program that works to mobilize community efforts at substance abuse prevention, which formerly was run out of Vanderbilt.
- CPH held 16 sessions of the revised three-day course, entitled Prescribing Controlled Drugs: Critical Issues and Common Pitfalls, with a total of 113 physicians from 14 states completing the three-day course. (see Sponsored Workshops in Bibliography.) Participants were surveyed at the end of the course on their satisfaction and their intent to change a number of aspects of their personal and professional lives. Among the changes participants committed to make include:
- Reducing prescriptions for benzodiazepines.
- Being more careful with the handling of prescription pads.
- Better documenting of prescriptions for narcotics.
- Increasing confrontations with patients on problems.
- Joining a (health professional) support group.
- Hiring an additional physician.
The following findings were reported in a range of articles, including the Federation Bulletin: Journal of Medical Licensure and Discipline (volume 85):
- In the vast majority of cases, the participants had prescribed large quantities of narcotics for back pain, migraine headaches, arthritis, and other "non-malignant" conditions. Often the participants had a history of being duped by drug-seeking patients, prescribing for office staff or close family members, or not documenting their treatment decisions in patient records. The majority of physicians referred to the CPH were in solo practices in small towns or rural areas. According to project staff, they had too many patients, too few colleagues, and too little guidance as they attempted to relieve pain and anxiety in their patient population. Some physicians had a drug use problem themselves.
- Participants come to the course for five key reasons:
- Core personality issues. Many of the participants are unable to say no to patients seeking drugs for pain, even if they are known drug seekers. Some have their own alcohol or drug abuse history.
- Family of origin issues. Many of the participants have first-degree relatives (parents, children, or siblings) with an alcohol or drug use problem.
- Problem patient types. These may include drug seekers with a pattern of dependency or abuse.
- Lack of pharmacological knowledge. Many physicians, for example, did not know about longer-acting narcotics for pain, which have a lower potential for causing dependency than do shorter-acting agents.
- Poor practice organization. Many physicians may prescribe correctly, but they fail to document their treatment decisions or to adequately explain them to patients or family members.
- Three months after the course ended, a follow-up survey of 54 participants (44 participants responding) indicated that the respondents committed themselves to making about 4 changes in their personal or professional lives, on average, and were successful 73 percent of the time. These results, which have been written up in an unpublished paper, are based on the participants' self reports; the project had no way to independently monitor changes in physicians' prescribing patterns. The most commonly cited reasons for not adopting the behavior changes were "lack of time," "anxiety about leaving unfinished work," or "continued heavy workload."
To effect greater change, the investigators suggest that the course may need to be supplemented with periodic "booster shots" in the form of individualized drug utilization reviews plus new sources for consultation, referral, interpersonal feedback, and support.
Project staff published three articles in professional journals, including Southern Medical Journal. The principal investigator made four presentations about the project, including one at the 2000 International Conference on Physician Health sponsored by the American Medical Association. (See Bibliography for details.)
AFTER THE GRANT
The CPH course on prescribing controlled drugs continues to be offered and is now self-sufficient (participants pay $900 and receive continuing medical education credits). CPH staffers have developed a companion course for physicians who engage in sex with patients or who cross other sexual boundaries. (A number of participants who had been accused of prescription violations also reported engaging in sexual misconduct with patients.) Based on the success of the CPH, Vanderbilt has developed a Physician Wellness Service for its health care professionals; the program incorporates CPH's course on prescribing controlled drugs.
GRANT DETAILS & CONTACT INFORMATION
Early Intervention for Physicians and Dentists Who Misprescribe Controlled Drugs
Vanderbilt University Medical Center (Nashville, TN)
Dates: November 1997 to October 2000
W. Anderson Spickard, M.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
CME Course Syllabus: Prescribing Controlled Drugs: Critical Issues and Common Pitfalls. Nashville, Tenn.: Vanderbilt University, 1998.
Spickard A, Dodd D, Swiggart W, Dixon G and Pichert J. "Physicians Who Misprescribe Controlled Substances A CME Alternative to Sanctions." Federation Bulletin: Journal of Medical Licensure and Discipline, 85: 819, 1998.
Spickard A, Dodd D, Dixon G, Pichert J and Swiggart W. "Prescribing Controlled Substances in Tennessee: Progress, Not Perfection." Southern Medical Journal, 92: 2028, 1999.
Swiggart W, Pichert J, Elasy T, Dixon G and Spickard A. "Continuing Medical Education Courses on Proper Prescribing of Controlled Substances in the United States." Federation Bulletin: Journal of Medical Licensure and Discipline, 86: 2028, 1999.
Spickard A, Swiggart W, Pichert JW, Dodd D, Elasy TA, Dixon GL and Butts NL. "Changes Made by Physicians Who Misprescribe Controlled Substances." Nashville, Tenn.: Vanderbilt Medical Center, Center for Professional Health, 2001.
Swiggart W, Pichert J, Elasy T, Dixon G and Spickard A. "Continuing Medical Education on Proper Prescribing of Controlled Substances in the United States." 2000 International Conference on Physician Health, American Medical Association. Poster abstract. Submitted October 1999.
Brochures and Fact Sheets
"The Center for Professional Health at Vanderbilt University: A Resource for the Southeastern United States." The Center for Professional Health at Vanderbilt, 1998.
"Physician Wellness Program." The Center for Professional Health at Vanderbilt, 2000.
"Half-Day CPH course,"fall 1998, Lebanon, Tenn. Attended by staff and referring physicians in the Pain Center at the Vanderbilt University Medical Center.
"Prescribing Controlled Drugs: Critical Issues and Common Pitfalls," January 1998, May 1998, July 1998, January 1999, March 1999, May 1999, July 1999, September 1999, November 1999, January 2000, March 2000, May 2000, July 2000, September 2000, November 2000; Nashville, Tenn. Each workshop was attended by 10 to 12 physicians who had been referred by their state board of medical examiners or physician health committee, for a total of 113 physicians attending the 16 workshops. The physicians came from Tennessee, South Carolina, Arkansas, Kentucky, Alabama, Texas, Louisiana, Virginia, North Carolina, Oklahoma, Wisconsin, Mississippi, Kansas, and Missouri.
Presentations and Testimony
Anderson Spickard, "Data on the Problems Associated with Prescribing Controlled Substances," at the Tennessee Nurses Association, April 14, 1998, Nashville, Tenn.
Anderson Spickard, "Presentation of the CPH program," at the 2000 International Conference on Physician Health, sponsored by the American Medical Association, April 1998, Vancouver, B.C.
Anderson Spickard, "Presentation on Work of the Center for Professional Health," at the Southeastern Regional Meeting, Federation of State Physicians Health Program, October 3031, 1998, Myrtle Beach, S.C.
Anderson Spickard, "Physicians Who Misprescribe Controlled Substances: An Intervention to Change," at the Annual Meeting of the Association for Medical Education and Research in Substance Abuse, November 58, 1998, Washington, D.C.
World Wide Web Sites
www.mc.vanderbilt.edu/cph provides information about the Physician Wellness Program and Continuing Medical Education courses offered by the Center for Professional Health at Vanderbilt University. Nashville, Tenn: The Center for Professional Health, 1997.
"Inextricabilis Error: The Labyrinth of Medical Error," in Federation Bulletin: Journal of Medical Licensure and Discipline, 1998, 85: 35.
Report prepared by: Susan G. Parker
Reviewed by: Richard Camer
Reviewed by: Robert Crum
Program Officer: Floyd K. Morris