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How Can Physicians Effectively Address Burnout?

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How Can Physicians Effectively Address Burnout?

How many of your colleagues are complaining that they are doing more work and getting less for it? How many of them are experiencing ever-increasing levels of frustration brought on by outside influences: governmental regulation, insurance regulation, increased concern about medical malpractice, increasingly negative attitude by society towards physicians, and weakened physician-patient relationships?

Most individuals considering medical school know up front that a medical career inherently makes certain demands – they will be called upon to place their personal lives on hold financially as they study and train in the field of medicine. Competition is expected, as is delayed gratification, personal sacrifice, limited sleep, lack of free time, and intense pressure to be up on the latest medical knowledge. Upon completion of their residency or fellowships, they may be able to reclaim certain aspects – they will begin drawing a paycheck, they will have more control over their daily routine, some will even “man their own ship” in private practice – but not all of them.

Unfortunately, the characteristics that a make a good clinician may also lead the physician further and faster down the road to burnout. The field of medicine and often the physicians themselves set very stringent standards to be followed. These standards can be identified in the form of self-imposed limitations.

Physicians must…

  • Work until the work gets done
  • Not permit downtime, as downtime is time wasted
  • Handle everything that comes their way without complaint or assistance
  • Be highly conscientious
  • Try to be all things to all people – patients, staff, family, colleagues, etc.

On top of all that, the medical environment brings other components. Physicians are faced with repetitive tasks on a daily basis. While the diagnosis may change, the seeing of patients often becomes routine as physicians move from one room to the next. Physicians are often faced with problems that lack solutions, accompanied by demanding and chronically ill patients. Life and death issues are faced on a daily basis. In short, there is no time to emotionally recharge.

After several years of holding themselves to such high standards, a number of physicians are being forced to reevaluate their career, their life’s decisions. Many feel increasingly dissatisfied with their daily lives, and struggle to find a coping mechanism.

Symptoms of Burnout

There are many symptoms of burnout, some emotional, others physiological. Just as he or she would query a patient about the symptoms of an illness, the physician must stop and query himself or herself to identify common burnout symptoms. Examples of these include:

  • Negative perceptions of self
  • Negative practice habits
  • Lack of empathy with patients
  • Unhealthy lifestyle
  • Dissatisfaction with career
  • Sleep disturbances

Identification of the symptoms, and eventually the cause, is critical for two reasons. First, it is the only way the physician can work to overcome burnout and its significant effects. Second, failure to address burnout can foster an environment where the “it-just-doesn’t-matter“ attitude turns into a malpractice claim.

Preventing Burnout

Given the above situations and environments, is it possible to cope with burnout? Research indicates physicians who take charge of their lives and strive to ensure balance, are far more successful than most.

Prevention and/or mitigation can be divided into several areas.

Physical:

  • You should acknowledge that you, too, can get sick, and you should take normal steps to prevent it.
  • Have an annual physical to identify health concerns promptly.
  • If you can’t get motivated alone, hire a personal trainer so someone is expecting to see you at the gym.
  • Ensure you get enough rest.
  • Maintain a healthy diet.

Environmental:

  • Maintain control of your schedule.
  • Schedule non-patient appointments when they are convenient for you, and assign a time limit.
  • Evaluate your other commitments; be willing to say no when asked to serve on just one more committee or handle one more obligation.
  • Set priorities. Identify your daily tasks and divide them into one of four categories: urgent and important; urgent but not important; important but not urgent; and neither important nor urgent. Try to take a realistic approach and avoid lumping everything into “urgent and important.”
  • Meet with your staff on a regular basis. This helps prevent their burnout, and subsequently yours if you are not having to deal with staffing issues on top of everything else.
  • Chart throughout the day. Several sources agree charting at the end of the day allows a dreaded task to cut into personal time.

Emotional:

  • Volunteer
  • Find a hobby or leisure activity that does not pertain to medicine to give yourself an outlet.
  • You should get involved in your church or a community project that is important to you.
  • Spend time with friends or colleagues where you can be yourself.
  • Modify your perspective. Instead of saying, “There is no way I can get all this done today,” say “I will do only that which I can get to today.”
  • Learn to handle conflict. Resolving conflict instead of just living with it will improve your emotional outlook in a number of areas.

Financial:

  • Avoid overextending yourself financially. Stress over finances makes most individuals feel they have given up control of their lives – they must now work to meet their financial demands, and not just to achieve career goals or personal satisfaction.
  • Indebtedness may prevent someone from implementing other key steps to preventing burnout.

Is it hopeless? No. Is it easy? No. But today’s environment is highly stressful, and unfortunately, it is not likely to change for the good any time soon. This means physicians must either learn to cope with the forces battering at them on a daily basis or continue to feel ever increasing despair and frustration from their chosen career.

Article contributed by Sae Evans and Maddox Casey, Members, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

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Two-Minute Primer on Electronic Prescription of Controlled Substances

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Two-Minute Primer on Electronic Prescription of Controlled Substances

The contents of a recent Drug Enforcement Administration policy statement on electronic prescriptions for controlled substances sound simple enough—you can use a mobile device for EPCS if it meets the latest Federal Information Processing Standards security requirements (FIPS 140-2), and you can use it as a “hard token” if it is separate from the device used to create the EPCS. But what does that mean? Are there any more limitations?

The Controlled Substances Act regulates drugs and other substances that have a potential for abuse and psychological and physical dependence, i.e., “controlled substances.” Controlled substances are organized into five schedules. Schedule I drugs have a high risk of abuse and no current accepted medical uses in the United States. Drugs in Schedules II through IV have currently accepted medical uses, but they also have a high potential for abuse. Drugs in Schedule II can only be issued pursuant to a written prescription, whereas drugs in Schedules III and IV may be issued pursuant to written or oral prescriptions.[1] The written prescription may be an electronic one, if it satisfies certain requirements.

An EPCS may be created with input and data entry from the DEA registrant (the prescribing practitioner) or his or her agent, provided that only the registrant can actually sign the prescription using the EPCS application.[2] To sign the application, however, the registrant has to complete a two-factor authentication process while at the same time viewing certain information about the EPCS (date of issuance; full name of patient; drug name; dosage strength and form, quantity prescribed, and directions for use; number of refills authorized; earliest date on which a pharmacy may fill each prescription; name, address and DEA number of the registrant)[3] and a statement of acknowledgement[4] regarding the EPCS, as prescribed by regulation. The provider’s completion of the two-factor authentication process in the EPCS application is the equivalent of signing a hard-copy paper prescription.[5]

The two-factor authentication process includes the use of two of the following authentication factors: (1) something only the practitioner knows (e.g., a password or response to a challenge question); (2) biometric data (e.g., a fingerprint or iris scan); or (3) a device, known as a hard token, which is separate from the computer or other device used to access the EPCS application (i.e., the hard token could be your phone, as long as you are not electronically prescribing the EPCS through an EPCS application on your phone).[6] The hard token is subject to FIPS 140-2 Security Level 1 requirements,[7] and the system used to validate biometric data must comply with other regulatory requirements,[8] all of which are beyond the scope of this article and beyond this author’s expertise.[9] Whichever factors are used in the two-factor authentication process, the prescribing practitioner/registrant must not share the authentication factors with any other person or allow it to be used to electronically sign an EPCS.[10] Additionally, if a practitioner/registrant loses his or her hard token (if applicable), he must notify the appropriate access control managers for the EPCS application (either in his/her individual practice or through an institutional provider such as a hospital) within one business day of the discovery, or he or she may be held responsible for any controlled substances written using his or her two-factor authentication credential.[11]

In addition to the requirements above and the responsibilities the practitioner normally has when issuing paper or oral prescriptions for controlled substances, there are more practitioner responsibilities when it comes to EPCS.[12] To the extent an EPCS is not successfully delivered, the practitioner must ensure that any paper or oral prescription issued as a replacement for a failed EPCS indicates that the prescription was originally transmitted electronically to a particular pharmacy and that the transmission failed. The practitioner must also exercise certain reasonable precautions to ensure that the EPCS application complies with all applicable regulatory requirements, especially if the practitioner is on notice that the EPCS system may not meet all the requirements.[13]

An exhaustive discussion of all the applicable requirements for EPCS is beyond the scope of this article. However, practitioners should be thinking about the vendors they are using for their EPCS system, the system’s capabilities and process control limitations, and the information security or physical safeguards they must maintain to ensure their two-factor authentication credentials are secure. In addition, it should be noted that EPCS are subject to other laws, such as the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which generally requires a practitioner to conduct at least one in-person medical examination for a patient if they are prescribing controlled substances for the patient.[14]

From a process standpoint, EPCS may be easier to work with, but it implicates substantial compliance concerns with a variety of laws. Practitioners should carefully consider the volume of legal and regulatory requirements applicable to EPCS and ensure their operations conform to all applicable requirements.

Article contributed by Christopher L. Richard with Gilpin Givhan, P.C. Gilpin Givhan, P.C. is an official partner with the Medical Association.

 

Resources

[1] Drugs in Schedule V may only be distributed or dispensed for medical purposes, but are not grouped in with either Schedule II or Schedules III and IV for purposes of the prescription requirements. See 31 U.S.C. § 829.

[2] 21 C.F.R. § 1311.135.

[3] 21 C.F.R. § 1311.120(b)(9).

[4] “By completing the two-factor authentication protocol at this time, you are legally signing the prescription(s) and authorizing the transmission of the above information to the pharmacy for dispensing. The two-factor authentication protocol may only be completed by the practitioner whose name and DEA registration number appear above.” 21 C.F.R. § 1311.140(a)(3).

[5] 21 C.F.R. § 1311.140(a)(5).

[6] 21 C.F.R. § 1311.115.

[7] Incorporated by reference in 21 C.F.R. § 1311.08.

[8] See 21 C.F.R. § 1311.116.

[9] This author suggests consulting with information technology experts in order to verify applications meet regulatory requirements, or at least include in agreements with vendors that the service they are providing complies with the applicable regulatory requirements.

[10] 21 C.F.R. § 1311.102(a).

[11] 21 C.F.R. § 1311.102(b).

[12] See 21 C.F.R. § 1311.102.

[13] 21 C.F.R. § 1311.102.

[14] See 21 U.S.C. § 829(e).

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It Began with an Email with Stephen Russell, M.D.

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It Began with an Email with Stephen Russell, M.D.

LEEDS – Benjamin Franklin said, “Either write something worth reading or do something worth writing.” For Leeds family physician Stephen Russell doing both comes naturally. As an associate professor of internal medicine and pediatrics at the University of Alabama at Birmingham, Dr. Russell is living his research for the characters he writes in his works of fiction, which are centered around Dr. Cooper “Mackie” McKay.

Dr. Russell has written and published three medical thrillers — Blood Money, Command and Control and most recently Control Group — with a fourth in the works. While he admits he has always written in some fashion, it wasn’t until he was in his residency in Cincinnati, OH, when he discovered he had a gift for the craft of storytelling. In fact, he credits the simple act of emailing with his father, who was a practicing cardiologist in Birmingham at the time, with stoking the fire of his love of weaving a good tale.

“I had been given an email address during residency and remember thinking, ‘Well, what am I going to do with that?!’” Dr. Russell laughed. “No one was really using email outside a school setting, but my father had an email address, so I used that as a way to communicate with him a good decade before cell phones were popular. Then I started to write these stories to him in my emails but completely different from an email you might think of today. I was taking all these stories that were really during an intense, emotional and academic time of my life when I was seeing new patients, learning how to treat them, and learning what being a physician was all about. I was retelling these stories of what my patients were going through, and what I was going through learning how to help them. In those emails, I was just beginning to learn how to put things together as a real story. Looking back on it now, those email stories had a character, a narrative arc, an event that happened, and the more I did them the more I realized there were patterns to my writing.”

Not only did Dr. Russell realize his love of the creative process through those early emails to his father, but he also learned just how much he enjoyed how cathartic the writing process itself could be.

Four years later, Dr. Russell began to wonder. “What if…?” Still practicing in Cincinnati, he had met hundreds of patients and had an arsenal of stories and medical scenarios. So, what next?

“I had this idea from things I had done during my residency. ‘What if?’” he wondered. “What if this particular thing happened and something bad happened as a result of it. I decided that instead of continuing to write short stories in the form of emails, I just dove in and decided it would be a fun to write a novel. I had never written a novel before. I had never taken a formal writing class before. I had taken literature classes in college, but nothing to prepare me for writing a novel.”

Dr. Russell is the first to admit writing his novels wasn’t exactly what he thought it would be. While he never expected to turn in his first draft and have it magically be published, he didn’t expect it would take 13 years from draft to publication.

“I had to figure out how to do it for myself by reading about writing great authors and trying to figure out how they wrote in order to do it well. I think if I knew now what I knew then…” he laughed. “What I didn’t expect was that I thought there was going to be this writing part of my life and this physician/professional part of my life. I expected them to be completely separate. But it was interesting to me that these two separate strands I thought were my two parallel lives were actually two parts of the same journey for me.”

As the two parts of his life began to converge, Dr. Russell said he wasn’t expecting the positive impact of being a published author would have on his patients. It turned out to be a pleasant surprise.

“I didn’t expect I’d be talking about writing while I was at work, or having conversations about books with my patients. Then the most amazing thing happened after my book was published. People read it! They would come in for their visits and would want to talk about the book and about writing, which was a great icebreaker. The thing I love most about writing is probably the thing I love the most about being a physician which is communication. My job as a primary care physician is to listen to my patients and interpret their stories and understand what they mean from a health standpoint. How does that story end? How can that story be changed? How can that story be interpreted for a better prognosis?

“That’s also the job of the writer…to create the story if it’s fiction or frame that story if it’s nonfiction and to package it in a way that clearly communicates whatever the writer is trying to tell. I didn’t think about it in those terms when I was writing my first novel, the second or the third, but as I started to be on the receiving end of other people reading my writing, critiquing it and giving comments, I realized that’s part of what I signed up for by entering into the arena as a writer, but it’s also what I signed up for by entering into the arena as a physician, which is just that ability to try and find a way to communicate what I’m doing clearly and try and help my patients communicate what they’re experiencing and feeling in a way that makes sense to them. That whole communication journey is what makes sense to me about why I enjoy writing but also why I enjoy being a primary care physician,” Dr. Russell said.

EDITOR’S NOTE: Dr. Russell has written three medical mysteries, which you can purchase on Amazon: Blood Money, Command and Control, and Control Group. He promises Dr. Cooper “Mackie” McKay will return in the future. In the meantime, he’s working on a young adult novel in which he’s getting plenty of input and primary research from his four children.

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Plan While You Still Can

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Plan While You Still Can

In our work with hundreds of medical practices, and in our Firm’s medical practice manager roundtable meetings, a common issue among medical practitioners is the uncertainty about the economic future of their medical practices.

Reimbursement levels may drop, many patients may choose medical coverage offered by a state-sponsored exchange, and the burden of changing technology is felt in many areas of practice. Since so many aspects of a medical practice are beyond the control of physicians, it is essential that doctors, in a private practice, exercise intentional control over the areas where they still can. This strategic planning is less daunting than many think, and can produce a more dynamic practice than you have experienced in years.

The process of strategic planning begins with an honest assessment of your practice’s current situation. Each physician’s candid opinions must be sought and considered in the development of an agenda for the group meeting. Since candor, among even the most collegial doctors in a given practice may be difficult to elicit, consider having an outside facilitator conduct these interviews. Based on the content of each doctor’s concerns, build an agenda for the planning meeting. It is recommended that these meetings be held at a neutral site outside the office but can be held in the practice conference room as long as no physician is permitted to exert his or her authority by sitting in their “power” chair or heavy‐handedly controlling the agenda.

Prior to the actual retreat, the administrator and facilitator must assemble background information and construct schedules necessary to answer as many fact‐based questions as possible. The goal of these schedules is to lessen the likelihood that a decision is postponed for want of additional data or a projection of the impact of the decision. Physicians are among the worst at group decision making. Some are so accommodating of their partners that they permit everyone to have “veto power” over any issue. Others let one member of the group require that the matter be tabled until every conceivable question can be addressed. Some groups apply their appropriately cautious medical decision-making processes to business decisions, which are not nearly as lethal or consequential. Whatever the reason, these result in what we refer to as Decision Deficit Disorder in medical practices. This too is a reason to have an outside facilitator.

With an agenda built on the issues of concern to all members of the group and background material developed for each point, the meeting is a time to make strategic decisions and assign tactical responsibilities. Select one of the easier matters for first on the agenda to establish a quick tempo, gain a positive perspective and promote participation by the entire group. If painful issues must be addressed, these should be handled privately unless that avenue has been tried and failed.

A sufficient content would be five to seven decisions, depending on the magnitude of the topics. We have been involved in planning processes where more than ten issues were resolved but a recent strategic process resolved five matters. In that instance, the group decided where to open a satellite office, determined to recruit two new physicians, renewed their commitment to reach out to referring physicians, decided to hire a marketing director for the practice and affirmed a plan to make their clinic days more accessible to patients. This proves that major things can happen when doctors focus on their own business needs.

 

Article contributed by Sae Evans, Maddox Casey and Jim Stroud, Members, Warren Averett Healthcare Consulting Group. Warren Averett is an official partner with the Medical Association.

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Just What the Doctor Ordered: An Alabama Perspective on the Opioid Epidemic

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Just What the Doctor Ordered: An Alabama Perspective on the Opioid Epidemic

Sometimes, Alabama is No. 1. In 2012, Alabama was the highest per capita painkiller prescribing state, with an average of 143 prescriptions written per 100 people — almost three times the rate of the lowest prescribing state.1 Alabama has been home to other No. 1s, too. In 2012, Dr. Shelinder Aggarwal, a former Huntsville-area pain doctor, was the top Medicare prescriber of prescription painkillers in the United States, until he was sentenced to 15 years in prison, had to pay back some $9.5 million in fraudulently billed claims, and surrendered his medical license in the wake of an examination by the Board of Medical Examiners.2

Many aspects of Aggarwal’s practice, which was described in the charging documents against him as a “pill mill,” are almost beyond belief. Aggarwal was seeing 80 to 145 patients in his office each day in 2012. Alabama pharmacies filled about 110,013 prescriptions (12,313,984 pills) in calendar year 2012 for controlled substances prescribed by Aggarwal. That equates to 423 prescriptions and 144 patients per day, assuming Aggarwal worked a five-day work week and wrote about three prescriptions per patient.3

Exactly how Aggarwal was able to prescribe controlled substances in such volumes is no less shocking. According to charging documents, initial visits entailed little more than a superficial physical exam and a urine drug test and lasted only five minutes. Follow-up visits could last as little as two minutes. Aggarwal allegedly did not retrieve a patient’s medical history, nor did he treat his patients with anything other than controlled substances. He was known to ask patients what medications they wanted, and he even wrote prescriptions for controlled substances to patients who admitted to using illegal drugs, or whose drug screen showed illegal drugs in their system.4

Aggarwal’s example, perhaps, is on the extreme end of the spectrum, but it highlights the gravity of the “opioid epidemic” Alabama and the United States are facing right now. Every physician has a role to play combating these opioid problems, and there are tools out there to help.

Prescription Drug Monitoring Program

The Alabama Prescription Drug Monitoring Program, or PDMP, is designed to “promote the public health and welfare by detecting diversion, abuse and misuse of prescription medications classified as controlled substances under the Alabama Uniform Controlled Substances Act.”5 Under the authorizing act and implementing regulations for the PDMP, any dispenser of Class II, III, IV or V controlled substances must report the dispensing of these drugs to the PDMP.6 Therefore, in most cases, you should be able to see any controlled substance (e.g. opioids) that have been dispensed to a patient if you check the PDMP. Although the PDMP authorizing act does not require prescribers to check the PDMP, they are allowed to access PDMP
information for a current or prospective patient,7 and their applicable licensure board may impose requirements to check the PDMP by regulation. Prescribers and dispensers should consult the PDMP and may suggest other health providers also consult the PDMP if there is information that may be important to the other health provider. Note: Neither the PDMP report nor any information from the PDMP report should be disclosed — that’s why you should suggest the other health provider consult the PDMP if you have a concern, rather than revealing information directly from the report.8

BME Risk and Mitigation Strategies Rule

The PDMP statute does not require prescribers to consult the PDMP, but certain licensure boards do. For instance, the BME recently finalized a new rule on risk and mitigation strategies (RMS) for prescribing physicians.9 The new rule requires prescribers to check the PDMP at frequencies that vary based on the morphine milligram equivalency (MME) of medications they are prescribing: (1) upon each prescription for controlled substances greater than 90 MME; (2) at least twice each year for controlled substances between 30 and 90 MME; and (3) consistent with “good clinical practice” for controlled substances less than 30 MME. Additionally, physicians are required to document the use of RMS in the patient’s medical record. Physicians should take care to adequately document appropriate RMS without running afoul of the PDMP prohibition on disclosing the PDMP report or the information contained therein. This can be a difficult task to fulfill when you can’t keep a copy of the PDMP report in the patient’s medical record.10 A simple notation in the patient’s medical record that you have checked the PDMP and that there are no contraindicated prescriptions likely would suffice.

The new RMS rule sets forth other RMS, including pill counts, urine drug screenings, patient education, and others, some of which are described below from the CDC. Physicians should note that failure to fulfill their obligations under this rule could lead to adverse licensure actions.11

CDC Guidelines for Prescribing Opioids for Chronic Pain

The Centers for Disease Control and Prevention, after a rigorous period of research, consultation and public comment, has also issued opioid prescribing guidelines for primary care physicians treating patients with chronic pain.12 Below is a brief description of the guidelines:

  • Consider nonpharmacologic therapy; only prescribe opioids if risks outweigh benefits;
  • Establish treatment goals;
  • Discuss known risks and benefits of opioid therapy with patients, as well as clinician responsibilities for managing therapy;
  • Consider prescribing immediate-release, rather than extended-release opioids;
  • Prescribe the lowest-effective dosage;
  • For short-term (acute) pain, prescribe the lowest-effective dose and only in the quantity needed for the expected duration of pain severe enough to require opioids;
  • Evaluate risk factors for opioid-related harms and implement a risk mitigation plan;
  • Review the PDMP for harmful quantities or combinations of controlled substances;
  • Conduct urine drug testing before starting opioid therapy;
  • Avoid prescribing opioids and benzodiazepines concurrently, if possible;
  • Offer evidence-based treatment for patients with opioid-use disorder.

A full report listing methods, clinical evidence, and a full discussion of the above recommendations are available from the CDC (see link in footnote 12 below for reference).

These are just a few tools to help you help your patients and mitigate the opioid epidemic. Let’s not win anymore No. 1s of the kind described above for the State of Alabama.

References

1 Prescribing Data, Centers for Disease Control and Prevention (Dec. 20, 2016), https://www.cdc.gov/drugoverdose/data/prescribing.html; Leonard J. Paulozzi, MD et al., Vital Signs: Variation Among States in Prescribing Opioid Pain Relievers and Benzodiazepines—United States, 2012, CDC: Morbidity and Mortality Weekly Report (July 4, 2014), available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm?s_cid=mm6326a2_w.

2 Huntsville Pill Mill Doctor Sentenced to 15 Years in Prison for Illegal Prescribing and Health Care Fraud, Department of Justice: U.S. Attorney’s Office, Northern District of Alabama (February 7, 2017), available at https://www.justice.gov/usao-ndal/pr/huntsville-pill-mill-doctor-sentenced-15-years-prison-illegal-prescribing-and-health.

3 United States v. Shelinder Aggarwal, Information Against Shelinder Aggarwal, Sept. 22, 2016.

4 Id.

5 Alabama Department of Public Health: Prescription Drug Monitoring Program Home (June 23, 2017), http://www.alabamapublichealth.gov/pdmp/index.html.

6 Ala. Code § 20-2-213 (1975); Ala. Admin. Code r. 420-7-2-.12 (Nov. 24, 2014).

7 Ala. Code § 20-2-214(2) (1975); Ala. Admin. Code r. 420-7-2-.13 (Nov. 24, 2014).

8 See Ala. Code §§ 20-2-215 to 20-2-216 (1975) (making records and information in the PDMP privileged and confidential and creating a Class A Misdemeanor for individuals who intentionally make an unauthorized disclosure of information from the PDMP); see also FAQ, Alabama Department of Public Health: Prescription Drug Monitoring Program (May 31, 2017), http://www.alabamapublichealth.gov/pdmp/faq.html.

9 See Ala. Admin. Code r. 540-X-4-.09 (March 9, 2017).

10 See FAQ, Alabama Department of Public Health: Prescription Drug Monitoring Program (May 31, 2017), http://www.alabamapublichealth.gov/pdmp/faq.html.

11 Ala. Admin. Code r. 540-X-4-.09(8) (March 9, 2017).

12 Deborah Dowell, MD et al., CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, CDC: Morbidity and Mortality Weekly Report (March 18, 2016), available at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm#suggestedcitation.

 

Article contributed by Christopher L. Richard with Gilpin Givhan, P.C. Gilpin Givhan, P.C., is a Bronze Partner with the Medical Association.

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