Common mistakes doctors make when writing opiate prescriptions

By Aaron Blackledge, MD

The most common mistake we doctors make is assuming it is someone else’s problem and not ours. We learned this the hard way at Care Practice and at our other jobs where we have been in the past. At Care Practice, our early attempts at saying we just wouldn’t prescribe Oxycontin or avoid doctor shopping was laughably flawed and a mess even though it seemed so logical at the time. What we learned was that we doctors will often come up with poorly thought out rigid rules crafted in frustration, only to have a little old lady walk in with a perfect story that gets us to violate the rule we just made the day before. This led to inconsistencies amongst different doctors and applying them arbitrarily. We were “experts” on addiction and yet had to learn the hard way that policies on prescribing need to be thought out carefully and discussed with the entire staff so they are fully understood and utilized uniformly. We physicians have a tendency to make the tragic mistake in thinking that our rules and requirements safeguard us against abuse. They often don’t and too often mistakenly impact real patients in real pain. Even worse we feel frustrated with ourselves and project it onto patients assuming we can somehow know who is the bad ones. These medications have the potential to train anyone to become an addict and our rules often only impact marginal players with poor acting skills. We don’t want to be the inexperienced DEA agents lurking in the international baggage area looking for nervous travelers. With 80% of these medications not being taken as intended, it is time we stepped back and look at the forest here. The rules doctors come up with are not working and in fact often serve as a road map for how to run circles around a clinic. The harsh truth is that the opiate patient that calls you friend, is always on time, that brings you cookies is more often than not, the one that has you fooled. All it takes is 1 hour of work bullshitting a doctor each month to write a prescription, and you can make up to $60,000 a year.

The stereotype of doctor shopping addict demonstrated by zdoggmd, who writes lyrics for doctors that make us feel like we are 13 again and every song was written just for us.

Sometimes the logical choice is actually the worst decision you can make.

Chronic Pain patients are some of the most difficult and problematic patients for doctors offices. The number of missed appointments, early refills, after hour calls, problems at the pharmacy, and general chaos makes them the number one source for frustration amongst most primary care doctors today. With this in mind it is understandable why so many would make the intuitive mistake of charging much more. On average, doctors will charge double the price for someone getting chronic opiate pain meds compared to a patient receiving a refill for hypertension medications. When Dr. Blackledge opened Care Practice he decided specifically under no circumstances would they charge more for these patients. At times he had to fight others understandable pushing to implement higher fees for problem patients. He benefitted from sage advice he his chief resident and given him to always be yourself and never compromise that principle. Because if you compromise your principles and accept things you don’t like, then you will wake up ten years from now with a practice full of patients you can’t stand and miserable. That advice helped him to see what might not seem clear in the moment when frustrated and dealing with a patient costing you time and energy. That charging an extra hundred and fifty dollars isn’t worth all those Friday night calls from the pharmacy or patients arriving 2 hours late and disrupting your entire clinic. Instead he would not charge and demand behavior change even when patients offered to pay more for the trouble.