How Pill Middlemen Like CVS Are Bilking the Health Care System

https://www.theamericanconservative.com/articles/how-pill-middlemen-like-cvs-are-bilking-the-health-care-system/

The outrage mob was at it again last week. This time, the target of their ire was, of all things, CVS Pharmacy. The fracas was the result of some clever antagonistic marketing by Pill Club, a San Francisco-based startup. It’s a company that acts as a sort of online pharmacy, providing customers with birth control pills and other contraceptives.

Angry with CVS Caremark over the high prices it was charging, Pill Club publicly insisted that the company was depriving women of health care. Of course, feminist Twitter outrage ensued and #CVSDeniesCare and #BoycottCVS quickly popped up. CVS, for its part, tried to quell the storm by releasing a statement saying Pill Club had been offered the same rates as any other pharmacy.

So it goes: CVS fell victim to yet another “leftist mob” demanding special treatment. For that, conservatives might be tempted to defend CVS against the slings and arrows of outrageous fortune. But the company doesn’t deserve it—not by a long shot.

CVS Caremark is a pharmacy benefit manager (PBM), a middleman between drug manufacturers and pharmacies—including online distributors like Pill Club. PBMs are hired by health insurers in order to negotiate prices, handle insurance claims, and oversee the distribution of drugs. Ostensibly, they should reduce drug prices, using their network to negotiate, making life easier for pharmacies, customers, and insurers alike. But this isn’t always the case.

Our Frankenstein’s monster of a health care system has created an abundance of “rent-seekers,” the term economists give to firms that exploit highly regulated markets and make profits they otherwise couldn’t. And PBMs like CVS are the worst of the bunch. They use monopolistic conditions, secrecy, and deception to inflate their profits at the expense of consumers, exploiting their role in America’s decidedly non-market health care system. As Republican Congressman Doug Collins once said, “they act as monopolistic terrorists on the market.”

CVS Caremark, Express Scripts, and OptumRx are some of the worst rent-seekers in the American economy. In a 2018 article, The Economist argued that PBMs, not drug manufacturers or insurers, were the recipients of the greatest excess profits in the U.S. health care system. According to the magazine, “excess profits from healthcare firms are equal to $200 per American per year” and “middlemen capture $126 of excess profits a year per American.” 

One of the main ways that PBMs seek rent is through their negotiation of rebates from drug manufacturers. And generally, to retain a PBM’s favor, drug manufacturers will readily cough them up. In turn, PBMs split the dough between themselves and the insurance company—placing the majority of it in their own pockets, of course.

Just how much, then, do they make off these rebates? Since the payments are kept strictly confidential, it’s hard to pin down the exact number. But considering the fact that insurers received $89 billion in rebates from PBMs in 2016, it’s safe to say they make a lot.

And it gets worse.

There are plenty of instances where a customer would actually be able to purchase drugs at a lower price without insurance. But PBMs don’t like this competition, so their contracts with pharmacies often include gag clauses—preventing pharmacists from even telling customers that cheaper options are available. According to the USC Schaeffer Center for Health Policy and Economics, prescription drugs are overpaid for 23 percent of the time.

PBMs like CVS have made a pretty penny off America’s failing system of employer-sponsored insurance. If the market were ever truly freed, they would be crushed. Prescriptions are a product, and they would finally be treated like one. After all, I don’t need a third party to negotiate the price I pay for a car. Why should my medicine be different?

America has embraced a broken system of employer-sponsored health insurance. Industry lobbyists have done everything in their power to ensure that alternative forms of health care coverage are limited. And it’s not as though government has proven to be much help. In 2018, Congress passed a law eliminating gag clauses and urging greater price transparency. But this proposal has drawbacks that ultimately limit its effectiveness. 

Something’s gotta give. As long as consumers are several steps removed from the actual processes governing drug prices, they’ll continue to be taken advantage of. It’s not as if these third parties are doing anything to stave off addictions or help Americans make wiser decisions about their medicine. All PBMs do is make people poorer in exchange for nothing. That’s why CVS doesn’t deserve anyone’s sympathy. If the outrage mob wants to take on one of the biggest bullies in the health care system, then let them fight.

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Scott Fitzgerald is news director at chanel 2 KJRH. He said email him & he will put a news crew on The Pain Patient Crisis. scott.fitzgerald@kjrh.com. Get the word out. Show him we are for real.

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‘Business decision’: Former DEA official works for opioid lawyers but set standards for how many pills were made

https://legalnewsline.com/stories/513448671-business-decision-former-dea-official-works-for-opioid-lawyers-but-set-standards-for-how-many-pills-were-made

In 2016, he was approached by attorney Richard Fields, who found major success in asbestos and breast implant litigation by taking on the insurance companies that issued policies to the corporate defendants.

Rannazzisi was hired as a consultant for Fields’ opioid team at $500 an hour. He testified that he has made more than $100,000, but less than $250,000.

Other sources of income include a one-time agreement with Motley Rice, which snagged a part on the opioid leadership team, to help with data from a federal database, and speaking fees.

“If it’s a parents group that lost children or loved ones, it’s free,” he said. “They pay me to come out and talk and – they pay me my expenses so they will pay my flight. Generally, I don’t even take hotel.

“If it’s a group of doctors, it might be anywhere from $2 to $5,000… (I)t just depends on the group and it depends on what they could pay.”

Asked what is the most he’s charged for a speaking engagement on the opioid crisis, he said it was $5,000.

Rannazzisi still has copies of DEA documents, having been told he couldn’t get rid of them yet. He denies sharing them with the Post and “60 Minutes.” He also says he hasn’t shared them with plaintiffs lawyers.

Fields, meanwhile, has few clients in the MDL when compared to some of his plaintiff lawyer colleagues – he represents just a handful of American Indian nations.

He does have the State of Delaware as a client, though. State cases are being heard in state courts, and the first state trial shows how lucrative that can be.

Private lawyers in Oklahoma have scored $80 million from settlements and stand to make another $90 million should a verdict against Johnson & Johnson be affirmed.

Delaware hired Fields and three other teams, referred to as the “Fields Team” in the contract, on a tiered contingency fee. It starts at 21% for recovery up to $50 million, then slides down a few percentage points for each $50 million added.

And Fields’ opioid lawsuit on behalf of the Cherokee Nation was the first to name pharmacies as defendants. In Congressional testimony, he said distributors were operating under the misconception that they had a quota to fill.

“This is an industry that allowed millions and millions of drugs to go into bad pharmacies and doctors’ offices, that distributed them out to people who had no legitimate need for those drugs,” Rannazzisi told “60 Minutes.”

There’s no denying the rise of opioids since the 1990s, but the question facing judges is who to blame. Private lawyers and the government officials who have hired them on a contingency fee basis contend that manufacturers, distributors and pharmacies ignored red flags and made it easier for addicts to get their hands on pills like OxyContin.

A popular defense is that the dispersal of opioids was regulated and federal officials approved what was happening. The combined quotas for oxycodone and hydrocodone nearly tripled from 2005-2015, when Rannazzisi was director of the DEA’s Office of Diversion Control.

The ODC increased the number of registrants allowed to prescribe and dispense opioids to more than 1.6 million under Rannazzisi, an increase of 45%. At the same time, the ODC took in registration fees that helped fund the department’s $300 million budget while more than 176,000 Americans died from their addiction.

In 2017, Democrat senators (including Dick Durbin) targeted DEA quotas, which rose every year Rannazzisi was in office. It took until 2018 for the DEA to issue a rule that requires it to consider the potential for abuse when it considers yearly quotas for production of prescription drugs.

Once the DEA sets quotas, it allocates a portion of them to the registered companies. Also at its disposal to track where opioids are going is a database called ARCOS which, Rannazzisi testified in 2007, was being used to identify excessive volume purchases.

Defense attorneys attempted to make the point, though, that the DEA under Rannazzisi rejected requests from companies that wanted to see their own ARCOS data, which could have aided in finding suspicious orders.

“Would you agree that access to ARCOS helps registrants combat diversion of controlled substances?” he was asked.

“Not necessarily,” he answered. “Because industry had other tools at their disposal to see downstream transactions that were not listed as business or proprietary.”

Rannazzisi said he did not know if those other tools include information contained within ARCOS.

As to the rise in quotas, defense attorneys pointed out that in the year Rannazzisi took office, the quota for hydrocodone was 37,604 kilograms. In his last year, Rannazzisi helped set the quota at 99,625 kilograms.

For oxycodone, the 2005 quota was 50,490 kgs. By 2015, it was 137,500 kgs.

“Now, by increasing the quota year after year, DEA was telling registrants and the public (that) pain medication should be available to support the legitimate medical needs; isn’t that correct?” he was asked.

“No. That’s not correct,” he said.

Rannazzisi shifted the blame for not flagging suspicious orders to the companies he was monitoring.

“And it was DEA’s policy not to tell registrants than an order is or is not suspicious, correct,” he was asked.

“Well, that’s a business decision that only the… distributor could make. They’re the only ones who know their customer. And they know what their customers are doing. And they know the… population around the customer’s business. They know what is in the area that could warrant an increase or not.

“So, DEA couldn’t make that decision. It had to come as a business decision from the distributor.”

The attorney asked, “So it was DEA’s policy not to tell registrants that order is suspicious?” and Rannazzisi reiterated his previous answer.

Asked why the DEA didn’t tell registrants to stop sales, he said there were “due process concerns.”

From Legal Newsline: Reach editor John O’Brien at john.obrien@therecordinc.com.

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The DEA’s Sole Pot Farmer Explains Why He Only Grows Shitty Weed

https://www.merryjane.com/news/the-deas-sole-pot-farmer-explains-why-he-only-grows-shitty-weed

He said 8% THC was “extremely potent,” and that only drug addicts needed stronger weed.

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Never Let an Opioid Crisis Go to Waste

https://www.spectator.org/never-let-an-opioid-crisis-go-to-waste/

When the Commission on Combating Drug Addiction and the Opioid Crisis advised the President to declare a national emergency to deal with the overdose epidemic, HHS Secretary Tom Price wisely suggested that this step wouldn’t be particularly useful: “[T]he opioid crisis at this point can be addressed without the declaration of an emergency.” Price is, of course, a physician who understands the public health implications of opioid addiction. He is also a former congressman who knows what kind of mischief the federal government gets up to when “solving” a crisis. Price was in Congress when the “uninsured crisis” spawned Obamacare.

Sadly, President Trump listened to less sagacious counsel and declared an emergency after all. If the White House and Congress follow the other bad advice offered in the commission’s interim report, they will produce another disaster for doctors and patients while exacerbating the problem they ostensibly wish to resolve. The most pernicious recommendation offered by the commission involves what the report dubs “prescriber education.” It calls for doctors, dentists, and every other provider with a prescription pad to suffer through mandatory courses — under the watchful eye of the Drug Enforcement Administration — to learn the “proper” way to treat pain:

Mandate medical education training in opioid prescribing and risks of developing an SUD by amending the Controlled Substance Act to require all Drug Enforcement Administration (DEA) registrants to take a course in proper treatment of pain. HHS should work with partners to ensure additional training opportunities.

The primary result of this ill-conceived recommendation will be far fewer prescriptions for all types of medication. But isn’t the problem caused by too many doctors writing too many prescriptions? Nope. The authors of the interim report claim, “We have an enormous problem that is often not beginning on street corners; it is starting in doctor’s offices and hospitals in every state in our nation.” In order to reach this preposterous conclusion, the commission had to studiously ignore a widely-documented decline in the number of opioid prescriptions that began at least seven years ago. In July, the Centers for Disease Control and Prevention (CDC) reported:

From 2010 to 2015, the amount of opioids prescribed in the United States decreased from 782 to 640 MME per capita.… Nationally, opioid prescribing rates leveled off from 2010 to 2012, and then decreased by 13.1% from 2012 to 2015.

Despite this decrease in opioid prescribing rates, mandatory education and increased DEA surveillance will soon render providers wary of prescribing any kind of controlled substance. Doctors will be so afraid of violating DEA rules that they will err on the side of caution. Patients with no history of, or predisposition toward, addiction will suffer needlessly because lazy politicians on a presidential commission have eschewed critical thinking and embraced hyperbole. Ironically, most controlled substances are neither narcotic nor addictive, and few patients are in any real risk of addiction. As geriatric specialist Thomas F. Kline, M.D. writes:

Out of 100 people taking pain medicine, only a very few, perhaps three or four, will develop an addiction. Restricting pain medicine in the other 97 is not good medical practice.… Deaths from narcotic overdoses usually involve multiple, non-prescribed, street drugs, not pain medicines prescribed by caring doctors.

But the report rejects dull reality in favor of sensational factoids: “The average American would likely be shocked to know that drug overdoses now kill more people than gun homicides and car crashes combined.” The average American won’t be “shocked” to learn that this is hopelessly misleading. To support their claim, the commission lumps together deaths involving all drugs, including heroin and cocaine, and fails to differentiate between overdoses and deaths resulting from the ingestion of multiple contraindicated drugs. Finally, the commission ignores the role government has played in creating the “crisis.” Which brings us to its second worst recommendation:

Grant waiver approvals for all 50 states to quickly eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases (IMD) exclusion within the Medicaid program. This will immediately open treatment to thousands of Americans in existing facilities in all 50 states.

This seems innocuous enough, at first glance, but disturbing data have emerged suggesting Medicaid is no panacea for this “epidemic.” Indeed, the program may well be driving the dramatic increase in opioid overdoses. A key provision of Obamacare involved coercing states into expanding Medicaid to able-bodied adults. The Supreme Court ruled that provision unconstitutional in 2012, permitting states to opt out of expansion. Since then, 19 states have done just that. What has all this to do with opioids? It turns out that the very real spike in overdoses seen in the Medicaid expansion states is absent from those 19 states. As Jon Cassidy wrote in this space in June:

Obamacare’s Medicaid expansion and individual insurance exchanges both went into effect in 2014. In just the next year, the fatal opioid overdose rate increased by 15.6 percent, CDC found.… The increase isn’t uniform. It’s clearly happening in 30 states, most of which accepted the Medicaid expansion. But overdose deaths have remained steady in 19 other states, according to the CDC.

How the commission missed the Medicaid connection is a mystery. Even the establishment media have taken notice. A headline in the Hill, for example, drew attention to the relationship thus: “Want to end the opioid epidemic? Start by freezing Medicaid expansion.” The author of that piece, Sam Adolphsen, points out that a patient covered by the program is 6 times more likely to die of an opioid-related death than someone with decent coverage. Adolphsen also points out that the Medicaid expansion in which Ohio governor John Kasich takes such pride has his state “on track to have more overdose deaths in 2017 than the entire United States had in 1990.”

All of this is lost on the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Chairman Chris Christie and its other members clearly believe that government meddling will end the “epidemic.” The rest of their recommendations all involve increased federal surveillance of doctors and patients, throwing taxpayer money at failed programs, and adding to the regulatory morass that is already killing our health care system. Before President Trump and Congress take further action based on the commission’s advice, they would do well to remember Ronald Reagan’s admonition about the nine most terrifying words in the English language.

The kind of “help” offered by Governor Christie and his accomplices on the commission is exactly what Reagan found terrifying. It will give government more power over patients and doctors while making the “crisis” worse. Here’s a novel idea: How about getting together a few actual physicians, people who actually treat actual patients, and see what they suggest? We have had a lot of government help during the last eight or so years. Do we really want MORE?

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There was a time when the opioid crisis was blamed mostly on prescription painkiller abuse. But new data suggests that opioid deaths in America are now largely due to an illegal synthetic form of the drug smuggled into the U.S. One America’s John Hines has more from Washington. Visit us at: Website: https://www.oann.com Facebook: https://www.facebook.com/OneAmericaNe… Twitter: https://twitter.com/OANN

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There are an increasing number of retractions of studies and published papers. Can we even trust what remains??

https://www.retractionwatch.com/2019/08/26/former-nci-postdoc-faked-data-from-nearly-60-experiments/#more-110187

Former NCI postdoc faked data from nearly 60 experiments

by Ivan Oransky

A former postdoc at the U.S. National Cancer Institute (NCI) made up data for 59 experiments that never happened, according to new findings by the U.S. Office of Research Integrity.

The ORI found that Rahul Agrawal “knowingly, intentionally, and/or recklessly falsified and/or fabricated:”

qRT-PCR data in fifty-nine (59) Excel files by: 

— conceiving Cycle Threshold (CT) values and PCR machine run identification numbers and run dates for fifty-nine (59) experiments that were not conducted

— inserting falsified and/or fabricated CT values in fifty-four (54) files that originated from one (1) Excel template with a single file creation date to represent distinct experimental runs with different experimental dates in exported Excel files from the PCR machine

— utilizing an earlier PCR machine calibration date in four (4) Excel files to represent experiments completed at a later date

CFC and FF assay images in four (4) PowerPoint files by:

— representing eight (8) images of CFC and FF assays in cell culture plates as the overexpression of LINC00379 or LINC00380 in human alveolar rhabdomyosarcoma RD and Rh41 cells when the cultured cells did not overexpress the specific LINC RNA 

Agrawal agreed to have any federally funded research supervised for a year beginning on August 8.

Agrawal, who was a PhD student at the Indian Institute of Technology in Delhi before becoming a postdoc at the NCI, did not respond to a request for comment from Retraction Watch.

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Can I Call Myself a “Pain Specialist?”

https://www.practicalpainmanagement.com/resources/ethics/can-call-myself-pain-specialist

Who defines the role of pain specialists? Do you qualify as one, and do the courts agree? Inside the legal requirements.

In April 2019, in the case of US v. Littleford, a Colorado physician was sentenced to 87 months in prison for overprescribing opioids that ultimately resulted in the deaths of at least two patients.¹ In just one day in 2012, the physician wrote one single patient prescriptions for 840 tablets of 30-mg oxycodone; 120 tablets of 80-mg oxycodone; 360 tablets of Percocet (10 mg oxycodone/325 mg acetaminophen); 240 tablets of 100-mg morphine; 240 tablets of 2-mg Klonopin (clonazepam); and 240 tablets of 350-mg Soma (carisoprodol). The patient’s file contained no documentation of an exam, a diagnosis, or a treatment plan. To make matters worse, the patient had disclosed in his intake questionnaire that he had previously undergone opioid detoxification.

In most aspects, the facts of the Littleford case were egregious and have little to do with typical pain management practitioners. Upon closer reading, however, the case does highlight one major issue that should concern everyone: who qualifies as a pain management specialist?

The Department of Justice (DOJ), in a press release regarding the case, stated that Littleford “…held himself out as a practitioner in the field of ‘pain management,’ although he did not have any certification in that field and had not completed a medical residency, which would have been directly applicable to the field of pain management.”² While that may sound like an obvious red flag to an outsider to the field of pain management, those of us with a deeper understanding may feel some unease at the DOJ’s statement.

Who qualifies as a “pain specialist?” (Source: 123RF)

Pain Specialists are in Short Supply

Unlike other medical specialties, such as pediatrics or cardiology, and despite what the DOJ seemingly implied, there are no independent residency training programs for the specialty of pain medicine or pain management.³ The medical residency referred to by the DOJ simply does not exist. Board certification in Pain Medicine is available, but a physician must first complete a residency training program in an entirely different specialty, such as anesthesiology, neurology, neurosurgery, psychiatry, or physical medicine and rehabilitation. Then, prior to obtaining board certification, the physician must either: (1) complete a one-year fellowship in pain medicine; or (2) provide proof of substantial training in pain medicine related-topics, and actively practice comprehensive pain medicine for a significant amount of time. This onerous path to pain specialization (in addition to the increasing scrutiny, and resulting fear, that pain practitioners face^4,5) has resulted in a severe shortage of pain specialists, with nearly 30,000 Americans living with chronic pain for every one board-certified pain care physician.⁶

With so few board-certified pain specialists, and so many people living with chronic pain, is board certification really the only way to qualify as a pain specialist? The answer will depend upon the authority that one asks.

State Requirements Matter

If one practices in a state that has adopted laws or rules that govern pain management clinics, the answer may be found within those policies. Georgia, for example, does require board certification, as the state requires all physicians who practice in a pain management clinic to have: 20 hours of pain-related continuing education in the preceding two years; and evidence of current certification or eligibility for certification in pain management or palliative medicine by the American Board of Medical Specialties or the American Osteopathic Association, the American Board of Pain Medicine, and the American Board of Interventional Pain Physicians.⁷ Ohio, on the other hand, takes a much more lenient approach, requiring only the physician owner of a pain management clinic (just the owner—not all physicians practicing in the clinic) to hold a subspecialty certification in pain medicine or hospice and palliative medicine.⁸ Texas requires no specialty or subspecialty certification at all, requiring only that each practitioner working within a pain management clinic obtain 10 credits of pain-related continuing education each year.⁹ Most states have no policies relevant to pain management clinics or specialists.

With no federal guidance on the matter, and with only a handful of states having adopted relevant policies, there is no clear answer as to who qualifies as a pain specialist throughout the majority of the country.

Policies Increasingly Recommend or Require “Pain Specialist” Involvement

While very few states have adopted policies specific to pain management clinics and specialists, many policies at both the state and federal levels recommend consulting with, or referring a patient to, a pain management specialist at various times during treatment. The CDC Guideline for Prescribing Opioids for Chronic Pain, for example, lists circumstances in which primary care providers (PCPs) should “…consider consulting a pain specialist as needed to assist with pain management,” but the guideline is silent regarding what would qualify a practitioner to call themselves a “pain specialist.”¹⁰ The states take a wide variety of approaches. Some, including Indiana¹¹ and New Hampshire,¹² require consideration of a consultation with a pain specialist for certain patients on high doses of opioids. Others, such as California,¹³ recommend a consultation with a pain specialist in specific circumstances. What all of the various state policies have in common, save for the very few with policies specific to pain management clinics, is that they fail to define who actually constitutes a specialist that would sufficiently fulfill the intent of the prescribing policies.

In Colorado, where the Littleford case took place, there are no statutes or regulations that specifically regulate pain management clinics or specialists. There is, however, an official recommendation that prescribers should consult with, or consider referral of the patient to, a pain management specialist prior to issuing high dosage “outlier” prescriptions for chronic, non-cancer pain.¹⁴ Found within the very same recommendations is a link to the Colorado Pain Society’s “Pain Management Provider Locator,”¹⁵ so it seems that the guideline’s authors realized that prescribers would need help in identifying pain specialists.

However, a quick perusal of this tool turned up only 75 total members in the entire state of Colorado. Of these, only 17 members indicated “Pain Medicine Specialist” or “Pain Management” as their specialty. Another 16 members of the Colorado Pain Society specialize in anesthesiology or interventional pain management (largely injections, not prescribing), and the rest represent a variety of disciplines including physician assistants, nurse practitioners, chiropractors, stem cell therapists, and even one office manager — a wide variety of disciplines that clearly do not qualify for board certification in pain management. Most of these practitioners are likely not the pain specialists that the guideline intended to target in terms of consultations regarding high doses of opioids, nor would they meet the “certification” or “residency” standards referred to by the DOJ.

Closing Pain Organizations Create an Unexpected Dilemma

While the Colorado Pain Society’s member directory may not be the ideal tool for identifying the types of pain specialists contemplated by the Colorado guideline, it is the tool that the guideline provides—so how else would prescribers find pain specialists if that society were to shut its doors?

In Arkansas, a physician managing a Chronic Pain Management Program must have completed and maintained at least one of the following: attendance at one meeting per year of a regional and national pain society; presentation of an abstract to a regional pain society; publication on a pain topic in a peer-reviewed journal; or membership in a pain society at a regional or national level.¹⁶ On its face, this requirement seems reasonable. However, since this regulation was initially adopted in 1996, the field has seen the closure of the American Pain Foundation in 2012,¹⁷ the closure of the Academy of Integrative Pain Management (formerly the American Academy of Pain Management) in early 2019,¹⁸ and now the impending closure of the American Pain Society.¹⁹ What happens to the status of a Chronic Pain Management Program in Arkansas if the managing physician was a member of AIPM or APS? Are their programs now in noncompliance? Given the very busy schedule of most practicing physicians, it is highly unlikely that most of them will have been published in a peer-reviewed journal within the past year, so what are they to do if they do not qualify for membership at another—still remaining—regional or national pain organization?

Practicing During Uncertain Times

With more than 20% of US adults living with chronic pain, and 8% of US adults living with high-impact chronic pain, specialists in the field of pain management are more needed than ever.²⁰ The last thing that our nation needs is for qualified and experienced pain practitioners to exit the field due to fear and uncertainty, so what can be done?

As is so often the answer in pain management, it is all about knowing your state’s local pain and prescribing policies, using your best professional judgment, and consistently keeping detailed records. To avert government scrutiny, prescribers should pay attention to, and account for, their aggregate prescription history and general prescribing patterns.²¹ Further, they should document utilization of opioid treatment agreements and their local prescription monitoring program, maintain strong provider-patient relationships, and utilize urine drug testing when appropriate. Finally, prescribers should always document when they consider consulting with, or referring to, another qualified pain management specialist.

If a prescriber has a specific concern related to their status as a pain specialist, they should consider contacting their licensing board for guidance and seeking an experienced attorney’s advice regarding compliance with local statutes, rules, and caselaw.

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