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:

1. 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.

2. Write that the patient accepts the risk of side effects.

3. 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?)

4. 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.