Issues Related to Medication Management in Chronic Pain Claims

Chronic pain is a complex problem often associated with psychological and social dysfunction, chronic disability and large health care costs. Medication management is an integral part of chronic pain management, and a variety of medications are prescribed for pain relief. Medications for which there is well established evidence of analgesic effi cacy include acetaminophen and non-steroidal anti-infl ammatories, tricyclic antidepressants, specifi c anticonvulsants and opioids. Other adjunctive medications for chronic pain include antipsychotics, centrally-acting muscle relaxants and benzodiazepines. Opioids are commonly prescribed for pain management. Although the role of opioids for the treatment of acute pain and cancer-related pain is well established, the long-term use of opioids for chronic non-cancer pain is more controversial. Support for the use of opioids in chronic pain appears to have gained momentum, particularly in the late 1990s.1 In the new millennium, there has been much speculation about problems associated with medication (and in particular opioids) used for chronic pain. Most of the concerns expressed relate to opioid-associated addiction, diversion to inappropriate sources, inappropriate opioid prescribing by physicians, and death associated with opioid poisoning.2-3 Prompted by these issues and an apparent increase in the role of medication management in anesthesia chronic pain liability from 2 percent of chronic pain claims prior to 1994 to 8 percent of chronic pain claims between 1995-99,4 we began collecting additional detailed information on medication management claims in 2005. We used this new data to investigate characteristics of chronic pain malpractice claims collected from 2005-08 and compared medication management claims to other chronic pain claims from the ASA Closed Claims Database of 8,962 claims. Specifi cally, we reviewed information relating to patient characteristics, treatment details, sequence of events, critical incidents, mechanism of injury, clinical manifestations of injury, outcomes and standard of care, and we performed indepth analysis of claims resulting in death. Medication management represented 17 percent of the 295 chronic non-cancer pain claims collected between 2005 and 2009. Most chronic pain management claims cited events that occurred in the year 2000 or later, with 82 percent of medication management claims occurring between 2000 and 2006. Compared to other chronic pain claims, medication management patients tended to be younger males [Figure 1] with complaints of back pain. Most patients were prescribed opioids (94 percent) with or without additional psychoactive medications (58 percent). Psychoactive medications (e.g., sedatives, hypnotics or muscle relaxants) tended to have sedating qualities.