Prescribe Oxycodone With Caution

Q.I have been following the growing controversy and legal action involving the medication oxycodone. It reminds me of the Phen-Fen situation of a few years ago in which psychiatrists were involved in litigation about the diet-drug combination even though these were not psychiatric medications. Do you see the current oxycodone controversy impacting psychiatrists?

A. Yes, we anticipate that the current controversy involving oxycodone will eventually impact psychiatrists.

Oxycodone is well established as an effective weapon in the treatment arsenal against severe pain; however, its addictive potential, as well as several well-publicized deaths and subsequent legal actions, have brought significant scrutiny to the use of the drug. As a result, the Drug Enforcement Administration (DEA) has taken the unusual steps of identifying and targeting it for enforcement activities. In addition, Purdue Pharma, the manufacturer of oxycodone under the brand name OxyContin, is attempting to reformulate the product to render it impotent when ingested by any means other than orally and has discontinued production of the 160 mg tablet. These efforts to reduce the abuse of oxycodone are laudable but have caused concern among physicians that patients who benefit from the drug may suffer as a result of more limited access.

Psychiatrists who prescribe oxycodone, who have patients taking oxycodone prescribed by another physician, or who have patients with a history of substance abuse should be aware of this developing controversy. Because of the unique training received by psychiatrists, they may be held to a higher standard than other physicians with regard to recognizing and treating the signs and symptoms of addiction or dependence in their patients.

Professional liability for improper prescription or administration of oxycodone, as with any medication, would be predicated on the psychiatrist’s deviation from accepted medical practice. Examples of such deviation include prescribing medication when it is not indicated, prescribing it without adequate consideration of contraindications, prescribing an inappropriate dosage, and failing to prescribe it when indicated.

Unlike most psychotropic medications, however, there is a high likelihood that oxycodone may place prescribing physicians in the unenviable position of having to avoid the intense scrutiny of regulators and law enforcement with regard to overprescribing, while facing, simultaneously, potential liability for undertreating pain. At least two physicians (nonpsychiatrists) have been charged with murder related to the deaths of patients who may have been abusing oxycodone, while, in contrast, a doctor was recently found guilty of elder abuse for under-treating a patient’s pain. It was alleged that he failed to prescribe a sufficiently powerful combination of painkillers.

Criminal charges against physicians based on their practice habits are extremely rare, but physicians may see an increase in such charges, as well as an increase in malpractice and licensure actions, against those who prescribe pain medication inappropriately. Unfortunately, criminal actions may raise coverage issues under a professional liability insurance policy due to the reality that criminal acts are not insurable. Of course, coverage must be assessed on an individual, case-by-case basis and is determined by the specific allegations made against the psychiatrist.

Psychiatrists should try to avoid allowing societal attitudes and fear to influence their clinical judgment. If a drug containing oxycodone is indicated, and it is clinically appropriate to prescribe it, then the psychiatrist should, by all means, prescribe it and document the prescription and treatment plan at least as rigorously as he or she would for any other medication.

More information on this topic can be found under “Advisories” at the Web site of the APA-endorsed Professional Liability Insurance Program at www.apa-plip.com. Participants in this program have access to its entire library of risk-management articles and tips including an online archive in the “For Participants Only” section.

More information on joining the program is available by contacting Leslie Cummings by phone at (800) 245-3333, ext. 389, or by e-mail at [email protected]. ▪

This column is provided as a service to the membership by the Psychiatrists’ Purchasing Group Inc., operator of the APA-endorsed Professional Liability Insurance Program.