Nurse Practitioners Fired for Negligence/Opioid Abuse

Nurse Beth, MSN

In addition to publicly calling out 64 physicians for overprescribing dangerous drugs, California's Death Certificate Project has now threatened the licenses of four nurse practitioners (NPs) for negligence after an investigation linked their prescribing to patients' fatal overdoses.

One patient who died was prescribed 200 oxycodone/acetaminophen tablets on discharge after his spinal fusion surgery. One month later, he called his NP and asked for a refill. This time he was prescribed 360 oxycodone tablets. The refill was prescribed before his first post-op check-up. He overdosed 3 days later.

California’s controversial Death Certificate Project, launched by the Medical Board of California, has resulted in both physicians and Nurse Practitioners being accused of overprescribing opioids. The program calls for review of all death certificates that list cause of death from drug overdoses with the full list of prescribing physicians.

If a patient died as far back as 2012 as a result of prescription opioids, any doctor who prescribed controlled substances to the patient within 3 years of his or her death is investigated. Deaths under review include deaths from suicide and death from street drugs.

Providers are terrified of being held responsible for the death of a patient they prescribed drugs for years ago and under past prescribing guidelines. Lack of documentation, such as failing to discuss non-opioid alternatives, and the risk of addiction, is used against the provider.

Proponents call it a proactive way to stop opioid abuse and weed out bad providers, while opponents say that good doctors are now afraid to order narcotics and treat their patients' pain.

Holy Trinity of Drugs

Nicknamed the “holy trinity”, this lethal combination of drugs includes a mix of opiates, anti-anxiety meds, such as clonazepam, and a muscle relaxer, such as carisoprodol. It’s a popular combination among drug users. Despite black box warnings warning against concomitant use and synergistic effect, users combine clonazepam with oxycodone with a muscle relaxer, which can result in sedation, coma, and death.

Drug-seeking patients will complain of severe pain, muscle spasms and anxiety to obtain their desired drugs.

Diversion

One case uncovered by the project involved an NP prescribing Temazepam for herself, while writing prescriptions for her boyfriend and her friends, combining benzodiazepines with narcotics. She ordered large numbers of pills and drugs that, when taken together, can cause death. She was observed to be under the influence at work, described as “wobbly” and “drugged”.

She was charged with gross negligence, incompetence and unprofessional conduct.

Reckless Behavior

Providers who use drugs themselves show increasing loss of judgement. They believe they won’t get caught and engage in increasingly inappropriate and risky prescribing practices. Some overprescribe to please boyfriends and friends. Some do it for the money, charging patients on a fee for prescription basis, or even selling prescription pads.

Other providers don’t recognize drug-seeking behavior in their patients and some overprescribe based on outdated practice guidelines.

In one case, the NP prescribed high doses of fentanyl without consulting a physician, steadily increasing the fentanyl dose. There was no comprehensive pain assessment and no documentation of the need for fentanyl. Lab tests showed the fentanyl levels to be 7X over the therapeutic range and in quantities and frequencies far above medically approved guidelines or practice.

In the case of the California NPs, where were the overseeing physicians?

While many NPs advocate for independent practice, CA NPs have DEA numbers but do not have full practice authority. CA is one of the 22 states that employs scope of practice restriction and requires NPs to work under physician oversight. Physician oversight is not a free service and physicians bill in exchange for providing oversight.

In many cases, physician oversight appears to be in name only.

Continuing Education

Does facing civil and criminal prosecution alone reduce over-prescribing behavior?

Should regular continuing education be required for safe prescribing of opioids?

Should providers be subject to routine drug checks, such as urinalysis?

Some believe that narcotic prescriptions should be in the hands of providers specially trained in pain management, pain specialists.

All agree that patients' pain must be managed while preventing dangerous opioid abuse.