I have exchanged emails with this particular chronic pain pts for a few years.. This pt has had adequate pain management on a opiate.. although the dose is quite high.. the dose has been fairly level for years. This pt is 50 something y/o, has been on opiate therapy for a couple of decades and is on Medicare/SS disability for years.
This pt told me this week that his/her prescriber has given the pt a ultimatum that the pt is going to have to undergo an evaluation trial of Prialt .. which can only be used in an implanted pump.
Prialt is derived from a toxin from a Cone Snail.. and is recommend for those people that are allergic to opiates and/or not able to achieve adequate pain management from opiates. Prialt can have some nasty side effects and – IMO – a pt should not undertake using this drug unless all other possible alternatives have been tried and failed.
What is strange is that this pt is having adequate pain management with the opiates now on.. thus Prialt does not seem to be indicated for this particular patient.
The cost of Prialt is in the $1200- $1500/month range ..plus a $20 K – $30 K to have a pump implanted.. and the battery in the pump has a life expectancy of 5 – 7 years. At which time a new pump has to be surgically implanted.. again at another large chunk of money.
The pt only has Medicare, which will cover 80% of the cost of the pump being implanted and the use of Prialt in the pump. However, the pt has stated to me that the co-pays and deductibles are unaffordable..
While the prescriber has not said the reason behind the ultimatum to go into a Prialt trial… it must have something to do with the fact that Prialt is a non-controlled drug and/or there is not a lot of money.. in writing monthly prescriptions for a opiate and/or the prescriber is just afraid of the DEA looking into the unusually high dose of opiates that the pt is taking… and the prescriber is prescribing. Where as putting in the pump.. will require regular refilling of the pump and additional charges to Medicare and revenue for the prescriber.
Apparently, if the pt does not agree to go along with the Prialt trial, the pt will be discharged from the practice.
The question remains.. is how does the prescriber justify medical necessity to Medicare.. when the pt’s chronic pain is being adequately managed on a oral opiate? The second question is what if the pt agreed to undergo the trial and the prescriber proceeds to convince Medicare to pay for implanting the pump and routine refilling of the pump.. and the pt gets behind in keeping up with the 20% co-pays and/or deductibles.. owed to the prescriber.. will the prescriber discharge the pt .. for failure to keep bills current ?
If the prescriber & pt continues with the pump being implanted.. could the prescriber be guilty of fraud/abuse of Medicare.. since the pt… fails the first parameter to justify the use of Prialt ?
It will be interesting in how this all shakes out.
Filed under: General Problems
You have been though a vicious cycle of indeterminate suffering at the hands of others. MRSA, nosacomal infection, among the irreversable delemnia you wish not to repeat. I cannot deny that these occur. Your Tx was not up to the high standards we espouse to be on the cutting edge. You have been a victim of the downside of shortfalls I would not wish upon any person, friend or foe. Good luck regardless and you may yet if not already find a reasonable amount of relief and justice.
I am in a similar situation. Opiates were refused, yet the pain doctor wrote that I had exhausted all forms of therapy (a lie) and would qualify for epidurals (never proven to help spinal cord injuries) and or the placement of a dorsal column stimulator. I don’t prefer either because with the back surgery, when I had my accident, I developed DVT(deep vein thrombosis) and MRSA. I don’t prefer to have either, again. My opiates were stopped and now I have to decide what part of the day I am going to suffer with my pain. The Tramadol that I receive is not enough. Ironically, I used to be a board certified general surgeon, certified by the American Academy of Pain Management, as well! Then I broke my back and acquired post traumatic cauda equina syndrome.