By Jeremy Wale, JD

Nearly every hospital in the United States provides anesthesia services to patients. Most offer surgical services with general anesthesia, providing for safe operative care of patients. Such services bring risk exposures, many of which you can proactively mitigate.

An emerging area of risk for anesthesiologists involves treating chronic pain patients.

Some anesthesiologists sub-specialize in pain management, in addition or instead of traditional anesthesia services. Some patients prefer facilities that provide chronic pain management.

Pain management presents unique risks requiring proactive assessment, direction, and mitigation. Allegations against physicians in this area can include, but are not limited to, failure to treat, accidental overdose, causing addiction, or death.

Considerations when Managing Chronic Pain Patients

Start by assessing whether your facility has anesthesiologists and/or other physicians managing chronic-pain patients. If yes, consider several important issues.

Do you have a designated area or clinic for treating chronic pain patients?

A centralized location for treating these patients helps your facility:

1. track patients and providers; and
2. establish facility-wide policies and procedures for handling this unique medical population.

Another consideration when providing care for chronic–pain patients is the physician’s qualifications for treating these patients. Pain management is a growing healthcare subspecialty, due in part to a reported 100 million Americans suffering from chronic pain.¹ According to the American Board of Medical Specialties, pain medicine is a subspecialty of anesthesiology, emergency medicine, and family medicine.

Consider employing board-certified pain medicine specialists in your clinic to treat chronic pain patients. These specialists’ additional education and training will help ensure your chronic pain patients are being treated by qualified physicians.

Your facility can implement policies and procedures to help lessen potential risks of treating patients who require pain management.

A strong risk-reduction strategy may require each patient to enter into a pain management contract with the treating physician. This contract clearly and concisely outlines the physician’s expectations of the patient and may include:

• The patient agrees not to accept narcotics prescriptions from other providers.
• The patient will not give or sell narcotics to others.
• The patient agrees to refrain from using drugs not specifically authorized by the physician.
• The patient is responsible for managing his or her medication to ensure he or she doesn’t run out before scheduled visits/refills.
• The patient agrees to random drug testing.

This is not a comprehensive list for a pain management contract. Consult with your physicians and legal counsel to create a document that best fits your institution’s needs.

Consider having a policy for ending your pain-management program’s relationship with its patients. While best handled on a case-by-case basis, a policy aids consistency. Situations such as illicit narcotics use, persistent missed appointments, or suspected drug diversion are more common instances that typically require action.

Also consider what to do when a chronic pain patient enters your facility’s ED. When these patients become addicted to opioid medications, they often run out of prescriptions early, and then try to secure narcotics by visiting the ED. An integrated EHR may help notify ED physicians these patients are being treated by a pain specialist; it may further aid understanding that the patient may not receive narcotic pain medications without consulting the pain-management physician.

Lastly, depending on your state, physicians may be able to monitor chronic-pain patients’ prescription history via an electronic prescription monitoring program. Several states implemented such programs to help fight prescription drug abuse and diversion. Depending on the state, physicians may review a patient’s prescription history. Be sure to review your state’s rules to understand what you may access.

Key Considerations for Your Hospital’s Anesthesia Services

The following summaries can help you and your facility’s leadership review policies and procedures to mitigate risks involved with anesthesia services, including those for chronic-pain patients.

• Does your facility treat chronic pain patients or have a pain management clinic?
• Do you utilize board-certified pain management specialists?
• Do your pain management physicians utilize a pain management contract? Is it sufficient?
• Does your ED have a protocol in place for handling potential drug-seeking patients?
• Do your ED physicians know how to determine whether patients are currently being treated by your pain management clinic or pain management physicians?

It is important for patient care and hospital liability that you take steps to proactively manage the risk around your facility’s provision of anesthesia and care of chronic-pain patients. Establishing sufficient protocol and frequently checking in with staff to ensure their understanding are essential steps in effective anesthesia management and addressing the needs of chronic pain patients.

 

1 IOM report. Relieving Pain in America. National Academies Press Web site. https://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research/Pain%20Research%202011%20Report%20Brief.pdf. June, 2011. Accessed June 6, 2016.

–Jeremy Wale, JD is a ProAssurance Risk Resource Advisor.