Is the crusade against pill mills turning into a witch hunt?
http://www.kevinmd.com/blog/2015/08/is-the-crusade-against-pill-mills-turning-into-a-witch-hunt.html
I care for a 65-year-old woman suffering from sarcoidosis affecting her lungs, her skin, her bones, her nerves, her blood chemistries, her kidneys, her colon and her mind. She has gone from an active spouse, mother, grandmother, tearing up the dance floors with her husband, to a home recluse calling friends to drive her to medical and care appointments while ambulating with assistance of another strong individual supported by a 4 wheel walker with a seat. She describes her foot pain as feet burning on fire.
When the Mayo Clinic suggested a biopsy on the normal colon and the pathology revealed a new entity responsible for all her symptoms she was reclassified from a neurotic, annoying wife of a professional to “an interesting and rare case” by many in the medical community. Throughout her trials and tribulations, she has sought the care of board certified gastroenterologists, nephrologists, urologists, rheumatologists, psychiatrists, psychologists, ophthalmologists, dermatologists, general internists and a neurologist specializing in pain management.
Our unfortunate chronic patient had her pain controlled by a board certified neurologist who through trial and error found a formulary that the patient tolerated. During the months of experimentation, the patient suffered through nausea, vomiting, constipation, diarrhea and dehydration. Trips to the ER for anti-nausea medications or IV hydration were frequent and common. When her neurologist found a mix that worked he stuck with it. That patient’s pain doctor moved out of Florida 3 years ago because he was afraid that the implementation of the Florida pain law would limit his patients’ access to needed medications and make his prescribing subject to inappropriate review and scrutiny. He is currently working at a university medical center in North Carolina providing patient care and teaching medical students and doctors in training.
As the patient’s primary care physician, I became the narcotic prescriber for the patient in her neurologist’s absence. The patient executed a pain contract with our office that she has followed religiously while she continued her care with her multiple specialty doctors. We tried several other neurologists and pain physicians but the high volume impersonal nature of medicine today left her unhappy and dissatisfied with the care and attention provided.
The alternative pharmacy — a popular supermarket chain — was audited by state regulators. The auditors were upset with the pharmacy releasing a controlled substance in the quantity given especially along with her antianxiety and anti-migraine headache medicines on this patient’s medication list. They had no patient records or history to explain why she was receiving these scripts, but nonetheless so intimidated the pharmacy that they called the patient and told her they would no longer be able to sell her the prescribed pain medicines. The patient called my office in tears wondering where to obtain her medications and frightened about the prospects of abruptly stopping these medications. The pharmacy simply said the liability and fear of losing their license necessitated the change in policy.
I am a board-certified physician in internal medicine, with extra study in geriatrics who has practiced in this community for 36 years. I list on my medical license application every two years that I will prescribe pain medications for legitimate chronic conditions. I take my required continuing education courses especially in the areas of prescription pain medication to meet the state requirements. My patients who receive chronic pain medications must execute a pain medicine contract that outlines their responsibilities as well as mine. I do not take lightly the prescribing of a controlled substance, but recognize that sometimes there are medical conditions that leave you with no other options. I have been told that after the state regulators look at the pharmacy’s role in prescribing short-term narcotics for long-term use, they will be contacting the Florida Board of Medicine to review my prescribing of these medications for this patient.
It is clearly an attempt to coerce and intimidate at the expense of a sick and vulnerable group of patients. I have probably prescribed fewer pain medications in my 35-year career than a pill mill prescribed in one day of business. The response to the Florida Board of Medicine will require hiring an attorney and involve time, research and aggravation. Our legislators, prosecutors, and law enforcement officers should be able to differentiate between a functioning medical practice and an illegal pill dispensary.
I am beginning to believe these same officials could not recognize the difference between a house of worship and a functioning brothel. Their inadequacies and inefficiencies threaten to prevent the citizens of Florida from receiving relief from pain even if they have a legitimate reason for receiving pain medication on a long-term basis. Do the citizens of Florida want their doctors making these decisions or legislators and bureaucrats with no clinical patient care experience?
Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.
Filed under: General Problems
“…officials could not recognize the difference between a house of worship and a functioning brothel. Their inadequacies and inefficiencies threaten to prevent the citizens of Florida from receiving relief from pain even if they have a legitimate reason for receiving pain medication on a long-term basis”
I’m not sure if he was serious or talking in jest. IMO ‘officials’ could care less. And doctors? Labeling, stereotyping, and uncaring. More concerned w/ regulators than their patients.
I found this case extremely interesting because it told of my journey through the medical system almost to a T. I also have sarcoidosis (along w/ MCTD/’lupus overlap’). B4 they found the CTD i was told repeatedly that sarcoidosis does not cause pain!! (despite neuro and general systemic involvement) Fast-forward 15yrs and they have approved ARA-290 as an ‘orphan drug’ to fast track it through to approval for Small Fiber Neuropathy (SFN) for sarcoidosis PAIN (also in diabetics) I found that after it was determined I had a connective tissue disease, my complaints/symptoms were taken more seriously as it was more widely known. I was able to gain pain relief and now worry about losing that. Anyone who has an AI disease, diabetic neuropathy or simply SFN from another cause may want to keep an eye on ARA-290. It is a novel medication as it not only relieves pain but actually REPAIRS nerve tissue and function. It is the first drug for AI diseases in general or related SFN I have seen that actually helps w/out suppressing the immune system but by REPAIRING the body’s tissues. VERY impressive and gives me hope for future treatments that may make opioids and steroids passe. (praying at least)
*Insight on how some doctors view those of us on ‘narcotics’ for CP.
Here is a VERY interesting series of responses to a new doctor asking for advice on how to deal with his pain patients. For whole thread: http://forums.studentdoctor.net/threads/opioids.1113660/
Q-“I feel my residency did not give adequate science-based training on how to take care of these frequently difficult patients. I think we can all agree that the narcotic thing is out of control here in the United States, but I feel that flat out saying “no” to people WHO HAVE MEDICALLY DOCUMENTED CAUSES FOR PAIN seems a little callous to me, when my honest desire is to alleviate people’s pain. Trying to have the conversation that opioids are not meant to be chronic medications, that they have been shown to actually cause hyperalgesia, etc, etc, nearly never goes over well with these patients either, despite them being completely true points that should cause any rational person to WANT to taper them. Narcotics contracts seem like a great idea on paper, but in practice seem to function as little more than an admission that they can always get their narcotics from me if they “follow the rules” which is still not something I desire to do. I’m interested to hear everyone’s opinion on this”
(I capitalized for emphasis above/below, otherwise unchanged)
Here are a couple responses he got:
1-For new patients, I told them that I don’t prescribe narcotics for chronic pain (exceptions for patients over 80 years if only 1-2 norco/day for documented arthritis).
2- *There are painful systemic inflammatory conditions that are much more effectively treated with low dose systemic steroids than opioids.
Patients seeking chronic opioids usually have, at the core of it all, problems coping with unpleasant sensations/feelings. They will want a hypnotic to sleep, a stimulant to wake up, muscle relaxers for their tender, unexercised muscles, benzos for anxiety, and of course opiates for pain. Naturally they smoke and drink too, and will never stop. This is why chronic narcotic patients seem “different” from other people. NORMAL PEOPLE WANT TO GET BETTER so they don’t need meds. For “chemical copers”, obtaining their drug of choice is the end point……
Never expect anyone else to take over opioid cases from you. It’s like asking someone if you can scrape dog crap off your shoe and smear it on theirs.
3-I agree with the THOUGHTFUL RESPONSES above. In my state, the Medical Board has gotten quite strict about contracts and urine drug testing. That is not how I want to spend my time. Those who are just looking for narcotics W/OUT WANTING TO GET WELL will not return,
From 12/14 so about 9 mos ago.
-Keep in mind these replies are for advice on how to refuse opioids to patients with LEGITIMATE CAUSES OF CHRONIC PAIN. Pretty scary.
*In my case, I agree, steroids do help more than narcotics BUT one could ‘theoretically’ develop osteopenia @ 43 and suffer two totally collapsed vertebrae (T-6 >80%/T-8 >90%) & 5 broken metatarsals in span of 6 mos). But at least I wasn’t given too high of a dose of ‘narcotics’.
While patients w/ pain are getting the short end of the stick time after time, I think we need to look at how this fits in to the big picture. It fits well. Despite having two incurable systemic autoimmune diseases known to cause pain I have been discriminated against and refused care @ pharmacies, doctors, hospital, etc. HOWEVER, I have also had much difficulty in obtaining non-opioid medications (not controlled meds). In 6 yrs since I have been disabled I have been denied about half of the medications prescribed. Luckily i have found some good doctors who have helped navigate the system and appeal these denials. They almost ALWAYS go through after you spend a couple hours on the phone to doctor, pharmacy, hospital, insurance company, etc. They are roadblocks to care. Insurance co. knows that half of those denied or refused will take no for an answer so it saves them money. Some doctors do not wish to spend their time dealing w/ ‘paperwork’ or dealing w/ insurance co or pharmacy. I have had a pharmacist tell me of physicians in town that will NOT appeal decisions no matter what. For myself i would NEVER keep a doctor who wouldn’t go to bat for me, but some patients either do not stand up and advocate for themselves or are older and just accept whatever a doctor tells them and/or are resistant to change. I take idea of comparing Drs to mechanics. If they dont fix my car why bring it back, waste of $$ no? This is getting harder as many drs just refuse to write for controls anymore. What does that say about our medical system and the overbearing weight of scrutiny cast by agencies such as the DEA? It is sad. Even the most conservative doc is going to come across patients who will need scheduled meds at some point, yet I have seen and heard from family and friends of offices w/ notices posted on the wall of waiting areas that read: We do not prescribe NARCOTICS.
The pendulum has swung back so far it has broken off. I fear moving for the simple reason that I am scared I am going to be weaned off or have drastic cuts to my medication regimen. It took several years to get to the point where my pain is well controlled.
The best letter thus far explaining what legitimate chronic pain patients goes thru on daily basis. My pharmacist had said to me once that he never thought that dispensing pain medication for a legitimate prescription from a legitimate respected Doctor for a legitimate diagnosis could result in him being threatened with possible arrest and/or loss of his license and lively hood. But that is what is happening here in Florida as a result of these laws and tactics !!! Legitimate pain patients are left to suffer the consequences and either commit suicide because they can’t stand the pain or they switch to street drugs to end their suffering. Which by the way is more easily obtained than a legitimate prescription for pain medication. What had this world come to ???? Pain patients are suffering and most to sick fight and our law enforcement and officials do not care. I can only pray they walk one day in our shoes so that they will be made to suffer like we are !!! Maybe then things will change then ! Lisa P.
Dr that was extremely well put. Her symptoms sound similar to RSD, which I have been suffering with for 5 years. The burning and electrical shock pain and bone crushing pain is very hard to control even with opiates. I cannot find a doctor to prescribe a combination of an opiate with xanax that actually gives me relief. The two cannot go together now for some reason even if it’s necessary. If I were a doctor, I would be angry beyond belief that all the years of training and clinical experience were being overridden by bureaucrats and law enforcement who have absolutely no knowledge of the disease or proper treatment or management of the disease or the specific patient. A day will come when there will be no Dr willing to prescribe opiates for any reason unless the people that are suffering can get their voices heard. But it is exactly these people that are homebound and only leave the house for doctors appointments and a rare trip to the grocery store. And don’t bother going to the emergency room because you’re only be labeled as a drug seeker. I now know that when I have a flare up, the only thing I can do is lay on the couch in agony and tried to hide it from my 12 year old son. In this country, pain that is pushing you to the point of madness is not considered an emergency. And my RSD happens to be result of a colorful plasti where the bone cement was too thin in consistency and went into my epidural space killing the axons in my nerves. Caused by the medical profession but no help from the medical profession. My life was ruined at 46 years old and I was working as a CPA and had a wonderful life. Now I worry about keeping a roof over my head on Social Security disability. I don’t think it’s too much to ask for a little pain relief we treat our animals better then we treat our humans in this country. Have a rally for save the whales or dolphins, loads of people will show up. Have a rally to make sure people in hospice have adequate pain relief during their dying days I bet you can count the people at the Raleigh on one hand.
Kyphoplasty
What assurance does the public have that the members of oversight boards are in fact ‘expert’ in their ability to regulate treatment decisions for practices and patients about whom they know nothing? What training guarantees anything more than a knee jerk political reaction?
Definitely well put. It’s pretty bad when the comparison is with the Salem Witch trials of our history. But it’s even worse when that analogy is so close to being true. Patients are suffering more and more everyday and the blame is on law makers and law enforcement. If they would have done their jobs to begin with, no one would be suffering because of prescription denial today.
It’s a little late for CYOA from law enforcement agencies.