Action by the North Carolina Medical Board

aaadrug OD rates

Last month, the North Carolina Medical Board (NCMB) announced they will query our state’s prescription monitoring program and investigate physicians identified as having worrisome prescribing habits. In order to help combat the prescription opioid overdose death crisis, this is part of an action that the NCMB is calling the Safe Opioid Prescribing Initiative.

Announced last month, the initiative will focus on three groups of physicians. This is taken directly from the NCMB’s website:

  1. The prescriber falls within the top one percent of those prescribing 100 milligrams of morphine equivalents (MME) per patient per day.
  2. The prescriber falls within the top one percent of those prescribing 100 MMEs per patient per day in combination with any benzodiazepine and is within the top one percent of all controlled substance prescribers by volume.
  3. The prescriber has had two or more patient deaths in the preceding twelve months due to opioid poisoning. (The initial group of prescribers under investigations were reviewed for the period beginning July 2014 and ending June 2015.)

The NCMB also says letters were issued to the first 72 prescribers (physicians and physician assistants) in April, most of whom were identified under the third criteria. Since nurse practitioners are also allowed to prescribe controlled substances, they will be scrutinized by the North Carolina Board of Nursing.

Responses to this new NCMB initiative have been mostly supportive. In my local newspaper, an editorial applauded the board’s actions, and advocated more such actions, to reverse the crisis of opioid overdose deaths in the state. The Charlotte Observer carried an article that said the NC General Assembly criticized the NCMB for not doing enough to combat prescription opioid overdose deaths

I’m probably not the NCMB’s biggest fan, but I don’t think it’s fair to blame that board for not doing more about the prescription overdose death crisis. The medical board wasn’t even allowed to access the prescription monitoring program’s data until the law changed last year to allow them to do so. Before that, they had no authority to do what the Safe Prescribing initiative outlines. In the past, they could investigate a physician only if they received a complaint about him or her.

Members of any state medical board have a thankless job. They are asked to make perfect judgments about medical professionals who may present a danger to the public. If they appear to be too lenient, they are criticized by the public for “protecting their own.” (This isn’t accurate anyway, since at least in my state, over one-third of board members aren’t physicians.) If they take strongly punitive stances, they are criticized for overstepping their authority and ruining the livelihoods of the professionals they license.

The professionals on my state’s medical board spend hours evaluating cases, for little or no pay. I think they may be paid nominal reimbursements for travel expenses, but I’m certain it doesn’t come close to making up for the time these people lose from their own businesses and practices.

Contrary to public opinion, state medical boards exist to protect the public, not to advocate for the doctors they license.

The NCMB initiative won’t be easy to implement, either. Just because a physician prescribes a whole lot of opioids doesn’t necessarily mean he’s a bad doctor. For example, a physician working with hospice patients, doing end of life care, should be expected to prescribe large amounts of opioids, and have frequent patient deaths.

Peer review of physicians will be essential. The NCMB will send charts of doctors identified by the three criteria above to be reviewed by other doctors in the same subspecialty. That means, hopefully, that doctors will be judged by other doctors in the same field of medicine.

This is important. This means that good pain management doctors may have to be evaluated and judged by other pain management doctors, through the NCMB. That will no doubt be unnerving, but the outcome should ultimately be positive, if the doctors are taking appropriate precautions.

Only doctors failing to meet accepted standards will have action taken on them by the NCMB, and only those actions will become public.

The NCMB has a big job ahead. They will need to separate the sheep of the doctor world from the goats, and decide appropriate actions to take. I do not envy them this task.

The NCMB has already taken action against many of the pill-mill type doctors, starting over a decade ago. If the board received a complaint, investigated a prescriber, and found him or her to be engaging in worrisome prescribing practices, that practitioner either lost the license to practice medicine, or was prevented from prescribing controlled substances, or was asked to take educational courses in proper opioid (or other controlled substance) prescribing.

I have other concerns about the third criteria of the NCMB’s Safe Prescribing Initiative.

First of all, how will the NCMB know if a prescriber has had two or more patient deaths in the preceding twelve months? I suspect the only cases examined by the NCMB will be those found to be opioid poisoning per the North Carolina Office of the Chief Medical Examiner (NC OCME).

Deciding if a prescribed opioid caused a patient death can be tricky. It depends to a large degree on the tolerance of the decedent, which needs to be determined by patient history. A dose of opioids that would kill one person won’t even make another person drowsy, if they have tolerance.

That factor is particularly important with methadone. My colleagues and I bemoan the fact that when our patients die, it WILL be blamed on methadone, no matter what. One doctor grimly remarked that if one of his methadone patients got shot in the head, the cause of death would still be listed as methadone toxicity. I think he’s exaggerating, but only by a little

The problem is that the North Carolina Office of the Medical Examiner has no standard case definition of what constitutes a methadone overdose death, which inevitably leads to mistakes about cause of death. According to information on their website and what I’ve learned by speaking with them, the decision is made by the blood level of methadone in the deceased.

I’ve felt the sting of being unfairly accused of killing patients. On several occasions, I’ve called the OCME about one of my patients who died while on methadone. I wanted to provide information about the patient’s dosing history before they determined the cause of death. I felt I had important information that could help them…but it did no good.

In one case, my patient had dosed on methadone 130mg for about a year, and then started a slow and steady taper. One year later she was dosing at 60mg per day when she died suddenly and unexpectedly. At autopsy, she had cocaine in her system, and she had a history of heart trouble. I suspected a fatal cardiac arrhythmia caused by cocaine, but the OCME announced the cause of death was: “Methadone toxicity, cocaine toxicity.”

Apparently they based their decision on post-mortem blood levels, known to be inaccurate. After death, the methadone stored in the liver can leak back into the blood vessels, causing elevated readings on which their determination was made, regardless of the history I gave them about her dose.

Five or so years before, another patient of mine died of what I thought was a severe asthma attack. In fact, she called 911 herself, saying she was having an asthma attack. Sadly, by the time EMS arrived, she had stopped breathing and couldn’t be resuscitated. I called the OCME to see what they found at her autopsy. The physician who did the autopsy said he found mucus plugging and bronchial casts, classic findings of status asthmaticus, which is a severe and sustained asthma attack. I was sad about her death, and told him I had treated her for many months for opioid addiction, and that she had dosed daily on methadone 75mg for at least two months.

When the death certificate was issued months later, after the toxicology report was available, I was surprised to see the cause of death listed as “methadone toxicity.” I called the medical examiner again and asked why this was listed, and the answer was that it was based on the drug level of methadone in her system.

Thankfully those types of cases are relatively rare.

I worry much more about all the people who die from opioid overdose who are never identified as a coroner’s case. That’s a bigger issue.

Consider the ways in which a deceased person becomes a coroner’s case. Of course, all instances where foul play is suspected require autopsies. Young people with no known medical issues should be investigated. Sometimes, deaths that occur in hospitals or nursing facilities require autopsy, if unexpected. Deaths that occur in police custody always require an autopsy..

In the community, if a person dies unexpectedly, a coroner is called to come to the scene to look for foul play. If there is none, the coroner calls the person’s doctor, to see if there’s an obvious cause of death like cancer or heart disease.

If you are a doctor freely prescribing opioids and/or benzos, what would you say to a coroner? Possibly, you’d say the decedent was ill with various problems and that the death was expected. It could be convenient to describe as “cardiac arrest.” (Technically, all deaths are ultimately due to cardiac arrest, but that doesn’t tell us the cause of death) This would be less upsetting for the family, keep the doctor out of trouble, and save the cost of an autopsy to the state.

Besides, no doctor wants to think the medications he prescribed killed a patient, or even contributed to the person’s death, so that inevitably biases judgment about cause of death by the prescriber.

I wonder how many overdose deaths slip through unnoticed and unexamined. Current data shows a very high incidence of prescription opioid overdose deaths, but I fear it is even higher.

 

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2 responses to this post.

  1. Dr. Burson – Thank you for your thoughtful comments about NCMB’s Safe Opioid Prescribing Initiative (SOPI). Your rational analysis of the program’s objectives is appreciated. As this is a new initiative, the Board itself does not know how successful it will be at identifying substandard care. We will know more when the first batch of investigations opened through SOPI are resolved sometime in September. In the meantime, I invite you to visit NCMB’s opioids page for more information and resources: http://www.ncmedboard.org/safeopioids

    Reply

    • Thanks for reading and thanks for your comment. It will be interesting to see how things develop. Personally I am so happy to see the NCMB targeting prescribes who write for opioid and benzos at the same time.

      Reply

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