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IDENTIFYING AND EDUCATING
Treatment with opioids sets the stage for adversarial actions, rendering doctors who prescribe opioids vulnerable to administrative, civil, regulatory, and criminal assaults. Opioids are believed, as a matter of faith, to be evil, dangerous, and even lethal. A strategy is needed to identify the potential litigants and adverse witnesses who will appear in these situations, so that they can be educated about pain treatment, and commit themselves in writing to the perceived benefits of such treatment. Without such a strategy, one often doesn't even know of the existence of these potential adversaries, until they appear on the witness stand to testify against the doctor who allegedly addicted or killed their relative.
This strategy targets the population that has the most pressing need to learn about opioids; the families of chronic pain sufferers. They are also the most likely candidates to become adversarial witnesses, if they are not educated. This approach identifies all members of the patient's extended family and educates them, prior to initiating opioid treatment. This amounts to a broadening of the concept of informed consent. Ultimately, this approach has the power to modify the belief system within our culture that makes prescribing opioids the most dangerous things a doctor can do.
Many who read this will object, because of the amount of work this approach seems to entail, and they will have concerns about how patient privacy will be impacted. The first concern is easy. This strategy can be implemented mostly by the clerical office staff, as it consists mainly of having forms filled out on a regular basis. The privacy concern is more troubling, but must be weighed against the threat that opioid prescribing presents to a doctor's livelihood, reputation, freedom, and in at least one case, even his life.
1) At the initial visit:
a. Have the patient fill out the "Family Tree" form.
b. After that form has been filled out and placed into the medical chart, present the patient with an informed consent form for each family member named in the family tree. This sequence of events is important, so that the purpose of the family tree form does not become apparent to patients who might choose to conceal the existence of family members who are opposed to their treatment. These are exactly the individuals who must be identified.
c. Each consent form must be returned before the start of opioid treatment, along with a copy of that relative's photo ID.
d. If any family member has questions or reservations about opioid treatment, these must be resolved before treatment is begun.
2) Testimonial letters should be obtained from all of the identified players at monthly intervals. This interval can sometimes be lengthened after treatment is stabilized. Testimonial letters serve several purposes:
a. Every family member stays on board with the treatment.
b. Each member recommits himself to report any concerns to the practitioner, allowing any problems to be addressed without delay, and preventing the manufacturing of such items at a later date for the purpose of adverse testimony.
3) Care must be taken so that this approach doesn't backfire in the courtroom. Plaintiffs attorneys and prosecutors will seize upon any perceived inconsistency.
a. The response to concerns expressed by any family member must be fully documented, along with whatever was done to resolve them. Otherwise, later it will appear that the practitioner was aware of a problem, and "blew it off". A written letter from the concerned family member explaining that the concerns have been resolved to his satisfaction should be obtained and place in the chart.
b. The interval on all testimonial letters should revert to one month, until such time as the situation has been stabilized for at least 3 months.
c. There should be a low threshold for referral for additional testing, or consultation with an appropriate specialist, whenever any concerns arise.