Practice Management, Safety, and Professionalism in Pain Medicine
Safe, professional practice
Document informed consent, diagnosis, goals, alternatives, risks, and shared decision-making. For controlled substances, check the prescription drug monitoring program, use a written agreement when appropriate, obtain urine drug testing, perform pill counts, counsel on secure storage and disposal, and set clear refill rules. Assess risk with validated tools but do not use them to deny care. Recognize pseudoaddiction, which is relief-seeking from undertreated pain, versus true addiction, which is compulsive use despite harm. Report impaired colleagues through proper channels, maintain boundaries, and avoid treating family members.
Privacy: HIPAA permits treatment disclosures but requires minimum necessary information. Mandated reporting varies by state for child and elder abuse and communicable disease. Billing must reflect documentation; avoid upcoding. Quality measures include function, adverse events, and opioid safety.
Traps: a positive urine drug test does not prove misuse because prescribed drug, metabolites, and lab cutoffs matter; a negative test does not prove abstinence. Do not abruptly stop opioids in physically dependent patients. Informed consent is a process, not a signature.
Worked example: before starting chronic opioid therapy, check the PDMP, calculate morphine milligram equivalents, assess sedation and constipation, and document a functional goal and follow-up plan. Rule: if you cannot document risk-benefit and monitoring, do not prescribe.