After a finding that he failed to show why several of his patients needed prescriptions, a Tucson psychiatrist is on probation with the Arizona Medical Board and is temporarily forbidden from prescribing certain drugs.
The board, which licenses doctors in Arizona, cited cases where Dr. David A. Ruben prescribed pain medication, including Oxycodone and OxyContin, to patients without properly verifying their need for them.
The medical board's report says that in more than one case, Ruben created a potential for abuse of the medications.
Ruben, a 1974 graduate of the University of Arizona College of Medicine, says he's agreeing to the conditions only to end the matter, not because he did anything wrong.
The disciplinary action will only further reduce an already depleted number of doctors in Southern Arizona who prescribe pain medication, added Ruben, who believes changes are needed in the way the Arizona Medical Board handles issues concerning the treatment of chronic pain.
"It's not black and white. Often these patients have depression. They may have addiction issues. Sometimes they can no longer work," Ruben said Friday. "It's interesting and complicated and an area that doesn't fit into the perceptions of the public, the politicians or the medical board."
Indeed, the Pima County Medical Society has asked the Arizona Medical Board to include an agenda item about chronic pain at an upcoming meeting.
Ruben is not the first Tucson area doctor to get in trouble with the board for prescription problems related to patients with pain. Between 10 and 15 local doctors have been either disciplined or cautioned for the way they prescribe pain medication over the past decade, society executive director Steve Nash said Friday.
There is a big street demand for such drugs, so doctors must learn how to detect the true patients from the dealers and addicts. As a result, many doctors just stay away from prescribing pain medication, Nash said.
The society is increasingly hearing from Southern Arizona patients looking for referrals to doctors who prescribe pain medication, and it's the third most common reason the public calls the local medical society. Nash said that there's a growing trend of local primary-care physicians refusing to treat patients with chronic pain. Some have gone so far as to put up signs in their offices, he said.
It's a problem that includes several contributing factors, among them medical education and federal regulation - not something that can be solved by the Arizona Medical Board alone, he noted.
The executive director of the Arizona Medical Board said the board cannot overlook deviations in the standard of care, even if fewer doctors are prescribing. Lisa Wynn also noted that the doctors who have been disciplined by the board for pain management issues have generally been pain specialists, and not primary-care physicians.
"What we do is protect the health and safety of the public by ensuring doctors are practicing safe medicine," Wynn said. "There's too much risk when the doctor isn't noticing red flags, not taking seriously their obligation to protect patients."
The red flags include frequent and early refills, and urine tests that are negative for the drug that's been prescribed.
"It's challenging. Opioids are very effective, but also very much in demand," she said.
The board has a set of guidelines about pain management for physicians. Among other things, the guidelines say doctors, "should not fear disciplinary action from the board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice."
As part of his agreement with the board, Ruben is on two years' probation and he can't prescribe, administer or dispense any opioids for one year. The restriction on his prescribing takes effect Aug. 10 in order to give his patients a chance to find another provider.
The board report cites several patients who received pain medication without documentation that Ruben performed tests to confirm their diagnoses or need for the medication, and in some cases there wasn't documentation that he monitored their use of the medication.
Ruben was disciplined by the board before. On April 1, 2009 the board gave Ruben a "letter of reprimand" and placed him on probation for one year. In that case, the board found that Ruben's conduct could have perpetuated a female patient's drug addiction. The psychiatrist completed that probation, including continuing medical education in pain management.
As part of his agreement with the board, Ruben agreed to take part in a periodic review of his charts. Board records say that Ruben's charts were randomly selected by the board's staff and reviewed by a medical consultant who found deviations in the standard of care in each case, as well as record-keeping issues.