The Knox prosecution

Doctors can't do all the thinking


I MAY not have all the details regarding Dr. Cecil Knox's supposed over-prescribing of Oxycontin, but, as a primary care provider, I have a few things to say about the subject in general.

It is my understanding that Knox was indicted on charges that included prescribing Oxycontin to 10 patients, three of whom died from overdoses of the drug when combined with large amounts of alcohol and seven of whom later sold it on the street.

I understand billing and coding errors were also found. Who of us, as providers, have medical practices that, if placed under the microscope of lawyers, peers and Medicare personnel, would pass all the tests of proper documenting and billing? We all make mistakes and most are unknown to us at the time.

But there is something wrong with a society that blames the doctor/provider when a drug is misused and places no responsibility on the patient.

If I recall correctly from last year's news, Knox went to the preliminary trial with dozens of current and former patients present. They informally testified on his behalf. Some said he was the only doctor with the courage to give them enough medicine for their cancer pain and that they were now able to work productively. Patients with pain who want to work! A medicine that enables them to be productive members of society! Hmmm. This sounds good to me.

Since the negative publicity for this physician and for Oxycontin, many physician/providers in the area began limiting pain medicines due to fear of litigation. Some placed signs that said, "We do not prescribe Oxycontin," and some offices issued statements that providers were not to prescribe anything past Schedule V for pain.

Some nursing home patients with chronic pain from cancer and debilitating arthritis were taken off their Oxycontin and placed on weaker, noncontrolled medications.

Most of the public does not know that many controlled pain medications have to be given every four hours, but that Oxycontin usually has to be given only every 12 hours and has fewer side effects than the other agents.

It also struck me that Knox was described as being the largest prescriber of Oxycontin "in the area." Well, he is a pain doctor. I would expect oncologists and pain management doctors to be the highest prescribers of this category of drug, just as a psychiatrist would be the highest prescriber of other controlled substances such as Xanax and Valium.

Responsible patients should not have to feel like criminals, on the run, traveling 300 miles to find a doctor willing to give them pain medications. And patients should not be allowed to sue doctors/providers when they failed to inform the provider of other potentially dangerous drugs they are on, including street drugs.

The question should be: Are we, as prescribers, responsible for how our patients take their medications after they leave our office? Where is personal responsibility? This is a society that even gave publicity to people suing McDonald's for their becoming overweight.

I believe people are responsible for themselves and what they put into their bodies. Why should any doctor or licensed provider (nurse practitioner, physician assistant) be responsible for what a functioning adult does on the outside after he or she has been clearly warned about side effects and the dangers of combining drugs? People have to become more involved and responsible for their own care and health.

It's time to grow up. We need to establish collaborative relationships with our trusted health-care providers, to realize we are a health-care team, patient and provider. We work together. We need to ask questions.

No one should be allowed to sue a practitioner when previously undetected cancer is found a year later on a diagnostic mammogram, when the patient was told to get the repeat mammogram in three months and then failed to show up. Patients need to follow directions, use calendars to record future advised tests, to follow directions.

I see providers undermedicating their patients for fear of litigation, or passing them off to pain-management specialists, who I sometimes feel are the bravest of us all. By blaming primary care providers for the irresponsible actions of a few of their patients, we attribute God-like qualities to them.

We must insist on patient responsibility. Nurse practitioners, physician assistants, doctors of osteopathy and medical doctors are asked to:

  • Advise a patient of possible side effects of medications, even though that side effect may have been reported in only 2 percent of patients who took a drug.
  • Write that the patient accepts the risk of side effects.
  • Make sure there are no potential interactions with other drugs. (Patients often fail to inform us of all the meds they are on. Are we supposed to call all the pharmacies in our community?)
  • Check that there are no precautions based on this patient's other illness, habits or exposures.

We are supposed to do all of this plus examine, diagnose and order tests for our patients, all within seven minutes to meet productivity requirements? Is it any wonder mistakes are made? We cannot do it.

We need responsible patients, patients who follow our advice; patients who question us, since we are fallible human beings who can and do make mistakes. We must empower our patients to choose lifestyles that promote their being productive members of society.

MARLA SPRING of Roanoke is a family nurse practitioner, nationally certified, and a medical legal consultant.

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