Tips to Help Doctors Deal with Opioid Requests and Avoid Malpractice Suits

By Roneet Lev, MD | Published 5/1/2017 1

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Photo source: iStock Photos

Drug overdose is the leading cause of accidental death in the U.S., and opioids account for over 60% of those deaths. While opioids are effective pain medications when used in the proper setting, concerns arise when the patient’s condition lasts longer than three months, and prescribing more medication does not necessarily result in better pain control.

Building a strong doctor-patient rapport can help facilitate tough conversations with patients about opioid prescriptions and reduce risks that could lead to malpractice suits. The Doctors Company reviewed 1,770 claims that closed between 2007 and 2015 in which patient harm involved medication factors. In 272 of these claims (15%), the medications were narcotic analgesics. Sixty-four percent of these claims were in the outpatient setting, including:

  • Physicians’ offices and hospital clinics (78%).
  • Ambulatory and day surgery (10%).
  • Emergency room (9%).
  • Patient’s home (3%).

The admitting diagnoses for these outpatient narcotic-related claims were pain not otherwise specified (NOS) (24%), spine-related pain (22%), joint/extremity-related pain (9%), mental health issues (6%), and drug abuse/dependence (4%).

Patient allegations for these claims included improper medication management or treatment (70%), wrong dose (9%), and wrong medication (3%). Final diagnoses in these claims included poisoning by methadone, heroin, and opiates/narcotics NOS (76%) and drug dependence (8%).

Communication problems are among the patient-contributing factors that lead to injury, appearing in 40% of claims. Incomplete or unclear communication can compromise patients’ ability to understand the doctor’s instructions and, especially in the case of pain medications, also make them feel as if the doctor doesn’t care about their issues or concerns.

These tips can help when dealing with opioid requests and prescriptions:

  • Don’t make the mistake of jumping to conclusions that the patient is a drug seeker because the patient is there repeatedly for the same pain complaint. It could instead be a situation of missed diagnosis. Treat this patient like any other patient. Take a good history, including a very detailed medication history. Do a thorough physical examination. See if something was missed on previous visits.
  • Your prescription drug monitoring program (PDMP) is a valuable tool, like checking allergies and old records. Use the PDMP to learn about your patient’s prescription patterns, not just to check for doctor shopping.
  • Medication refills for chronic conditions should have a medication agreement. ONE doctor and ONE pharmacy should prescribe controlled medication given for three months or more. This is true for dental pain, fractures, fibromyalgia, cancer, anxiety, and ADHD. If you see a patient for the third month of a controlled medication, start a medication agreement if you plan on continuing this therapy.
  • Opioid withdrawal is uncomfortable but not life-threatening. New patients who present to a new pain specialist should not immediately be given the pain medications they state they need. A pain specialist typically completes thorough research before making medication recommendations and it could be two weeks before the patient is placed on a regular regimen. You may find it necessary to send a patient home without a pain prescription if that patient has already received one in the past month from a different provider.
  • When patients say that their medication is not working, ask the patient, “How are you taking the medication?” You’ll be surprised how many patients used 400mg of ibuprofen twice a day and it was not enough. Taking a detailed medication history and providing patient education about the right dosage, right timing, and side effects to be aware of is essential to medication safety.
  • When you hand a patient a prescription for a controlled medication, add a few words to let the patient know that these are serious medications: “I will give you a prescription for Norco. Please realize that this is a medication that can be abused. Keep it secure, take it only as prescribed, and do not drive if not fully alert.
  • Be aware of the level of health literacy of the individual patient, and adjust your language appropriately. Ask patients to repeat back the information you gave to ensure they properly understand.
  • Communicate the risk of medication theft to patients. Patients who are on a chronic treatment plan should know to watch their medication as closely as they would their money.


Good answers for specific patient questions and situations:

“Can I have something for pain?” “Yes, let me check your medical record for the best choice.”
“The medicines don’t work.” “Can you please tell me how you take the prescription?”
“My prescription was stolen.” “Did you file a police report?”
“I have chronic pain.” “For your safety, you need your medications coordinated by one doctor and one pharmacy.”
“I received extra pain medications elsewhere.” • “Let’s do a drug specimen today.”
• “I see you received 20 pills from the emergency department, what happened?”
• “OK, to stay on the same schedule, this month I will write 100 tablets (120 minus 20).”
A case of clear doctor shopping “I am concerned because your medications can be addicting. I am going to refer you to someone who can help with this.”
A case of need to stop an opioid prescription “The medication no longer appears to be as beneficial as it once was. As the benefits of the opioids no longer outweigh the risks, we need to discontinue this approach and together find a safer and more effective means of dealing with your pain.””

More safe prescribing resources are available at You can learn more about effective doctor-patient communication at httpss://

This post was sponsored by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer.

Roneet Lev, MD


Roneet Lev, MD FACEP graduated from the University of Texas Medical School in San Antonio and completed her emergency medicine residency training at the University of California San Diego. She is dually board-certified in emergency and addiction medicine, bringing over 25 years of experience treating the frontline cases of addiction.

She is a nationally acclaimed medical expert and speaker who continues to treat patients in the emergency department and hosts a podcast titled High Truths on Drugs and Addiction. is a podcast and a movement in bringing relentless advocacy to unify addiction medicine with mental health and physical health. Dr. Lev fights for her patients, the American public, and communities. She brings out-of-the-box solutions to the prevention and treatment efforts on addiction.

She served as the first Chief Medical Officer for the White House Office of National Drug Control Policy from 2018 – 2020.

Dr. Lev’s medical publications known as the “Death Diaries” studied the details of prescription patterns of people who died from accidental medication drug overdoses, giving insight to the causes of overdose and directing prevention efforts.

Awards and Recognition

• Her program on Safe Prescribing in the emergency department won the 2014 National Association of Counties award.

• Dr. Lev served as President of the California Chapter of the American College of Emergency Physicians in 2000.

• The California US Attorney's office nominated her for the White House Champion of Change Award

Clinical Leadership

• Dr. Lev served as President of the California Chapter of the American College of Emergency Physicians in 2000.

• In 2012, she established and chaired the San Diego Prescription Drug Abuse Medical Task Force. The first of its kind in California that integrated physicians of various specialties along with hospitals, law enforcement, hospital administration, treatment programs, and public health for the purpose of decreasing deaths and mortality from prescription drugs.

• Dr. Lev was the first Chief Medical Officer of the White House Office of National Drug Control Policy, ONDCP, 2018-2020. She brought refreshing frontline medical experience to national health policy.

• She is Founder and President of, Independent Emergency Physicians Consortium, an organization providing collaboration to independent emergency departments in California.

• She is one of the founders of an IASICI.Org, Internation Association on the Science and Impact of Cannabis and established a medical library that is accessible to the lay public.

• She presently practices emergency medicine at Scripps Mercy Hospital in San Diego.

Dr. Lev continues to practice medicine on the front lines and consults on clinical medicine and health policy. Dr. Lev uses data to drive change and is frequently quoted in print and television media.

She is an energetic leader with a passion to assist communities in preventing and treating addiction. She continues to practice medicine on the front lines and consults on clinical medicine and health policy.

Dr. Lev is a proud mother of 4 children. In her free time, she enjoys hiking and training her new German Shepherd puppy.


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