Over-Prescribing Schedule II and III Narcotics By Jeffrey J. Tonner, J.D.

How A Dentist Is Reported
America's pharmacies now are tightly computerized. The apothecary usually is the first person to recognize an unusually large narcotic output for a particular individual. When this occurs, s/he has the option of notifying several sources: the dentist; DEA; or dental board. Often all three are involved. The pharmacist may telephone the DEA, who in turn notifies the dental board. An investigation or claim can then be opened against the dentist. Often, this formal route is the practitioner's first notice.

Staff Problems–Negligent Supervision
Many dentists are lax with internal office controls, trusting the office manager and others to oversee prescription writing and other perfunctory tasks. Practitioners feel that as long as the prescription data accurately are recorded in the treatment notes, then they are safe. This may have been true twenty years ago, but not today.

Sometimes the staff forge names, lie and manipulate the system to procure narcotics for themselves or friends. While the dentist cannot be held directly accountable for these criminal acts, the overpopulated plaintiffs bar may invoke the indirect tort of negligent supervision. In other words, what safeguards were in place for the "captain of the ship" to reasonably nip a potential problem in the bud before large damage is inflicted?

Internal Office Protections
Standard office protocol is for the front office to prepare the billings and scripts from the doctor's treatment notes. The staff manually or via computer certainly can be trained to transcribe the drug name, dosage and delivery instructions to the pad. From there, however, the dentist should: personally sign all scripts; never sign her or his name in advance; use serially numbered prescriptions; keep excess pads under lock and key; institute an office policy that only the dentist discusses pharmacy inquiries.

Remember that internal controls need only be reasonable, not foolproof. The test is whether your backup systems can stop a problem before it spirals out of control. If a staff member can be thwarted before the illegal narcotic usage reaches addiction, then you should be safe.

Signs Of Potential Drug-Abusing Patients
Drug-dependent patients may exhibit some or all of these signs: request a specific narcotic by name; when you suggest an alternative, they indicate your selection is ineffective for them; balk at the low number of narcotics allowed; are difficult to anesthetize; pay for services in cash.

You may wish to chart this distinctive behavior:
10-05-01 Pt requests Percodan by name. Says only it relieves his pain. Told pt I do not prescribe it, but offer[alternative]. Pt becomes angry and refuses any Rx.

One common trick of the trade is to claim that an appointment with a specialist is forthcoming, but pain killers are needed for a few days. Some patients are successful in garnering hundreds of narcotics in a single day by duping multiple dentists into writing prescriptions of 20 to 40 each.

Another caper is the so-called "golden tooth." This involves a tooth that clearly is dentally compromised and is certain to cause pain. When drug use is suspected, consider suggesting extraction as the litmus test and then gauge the patient's reaction. Drug addicts will protest profusely, since losing the golden tooth would alleviate the need for future narcotics.

Must You Prescribe Narcotics At All?
You need to address a patient's pain complaints, but not necessarily with Schedule II or III narcotics. A strong non-narcotic prescription can be used in your professional judgment. Prescribing Ibuprofen 800 mg or a similar alternative is acceptable treatment.

When taking call for another dentist, consider a mutual prearrangement where no narcotics will be prescribed to each other's patients. Such a pact makes it easy to say rio to narcotic requests from unknown callers.

What Is The Overprescription Threshold?
I represented a general dentist who had prescribed over 5,000 Percodan (not a misprint) to an individual patient. She became an addict and filed a lawsuit. In 1996, an Arizona jury awarded this patient $1.8 million in a combination dental/pharmacy malpractice action. The liability was assessed approximately 50% to the dentist, 25% to the pharmacy, and 25% to the patient (contributory negligence). Fortunately we settled during trial; othenwise, the dentist would have paid $900,000.

In defending this action, I canvassed hundreds of dentists to determine the appropriate level of narcotics. While my informal poll certainly lacks statistical significance and does not represent the standard of care, the vast majority of the dentists agreed that prescribing more than 100 pills within a continuous time period was excessive.

Jeff Tonner is a Phoenix attorney. His practice encompasses the dental-legal arena defending dentists in malpractice or board action; writing educational books, manuals and articles; and presenting risk management seminars. Mr. Tonner has just published a new-concept manual, entitled, Ideal Charting for General Dentists--Superior Entries in Less Time. The book contains suggested entries, like those shown in this article. To order call: 602-266-6060 or email Jeff at: dentlaw@jefftonner.com.