By R Carter
We must take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented.Elie Wiesel
Who are the innocent victims in the opiate war?
At many levels, government recovering its losses due to the opiate crisis, business interests trying to remain profitable or cut costs, healthcare providers protecting themselves from liability concerns, each has collectively worked together to push out of the conversation, other important issues. Issues such as increased access barriers, ethical, HIPAA or civil rights violations. Fortunately these kinds of issues are not wide spread, but they are growing in frequency and may affect millions as government squeezes healthcare and businesses scramble to protect profits. During a recent conversation with my primary care provider, without prompting, she verbalized her concerns that it was just a matter of time before doctors were squarely in the target sites of patients who would start suing providers because providers were knuckling under the pressure placed on them by irrational state guidelines and failing to address patient needs in pain management. Such unsolicited thinking out loud is another sign that prescribers understand what the problem is, they are just too afraid to speak out against it. Until we the people push back, as some of us are doing, the status quo will remain and citizens will not know just how far their rights have been eroded nor will they understand how vulnerable they are to being helpless, powerless, unable to defended themselves nor protect themselves after having had an accident and thrown into a healthcare system which will literally allow them to suffer in agony.
Don’t kid yourself, in any war there are always civilian casualties and in the war on opiates, the innocent victims have been both doctors and patients, but patients more so than any other group. By far the, majority of these patients are otherwise normal individuals who through no fault of their own, have a medical condition where chronic pain is a major component. Those who lump chronic pain patients and illegal drug abusers into similar groups; expose their own myopic views and bias. And they do so in the absence of empirical data supporting such conclusions. Such behavior is not unlike imprisoning U.S. Japanese citizens following the attack on Perl Harbor in the 1940’s.
Actions which create barriers to accessing healthcare for chronic pain occur on multiple fronts, impacting patients directly, or indirectly through third parties. Here are a few which I have personally witnessed.
- Limits or restriction on which doctors may prescribe and under what conditions.
- Limits om which pharmacies may fill a script.
- Labeling individuals as at risk for overdoses based on CDC guidelines which fail to take into consideration such factors as:
- The system failing to live up to its own standards.
- The rush to judgement for the sake of profit, cost cutting, time management.
- Private individuals and entities failing to take responsibility for their part and role because it was forced on them by government regulations.
- Defining conditions so broad and loose that they could easily apply to anyone, allowing anyone to claim an individual is a risk and doing so in the absence of any proof.
- Rising liability insurance rates for pain specialist.
- Doctors and clinics forced out of business due to government reforms, increased bureaucracy and regulations.
- Generalized, incomplete and ambiguous guidelines creating fears over liability concerns by practicing physicians, resulting in ethical and civil rights violations against patients.
- Broad discretionary powers given government agencies which investigate and enforce regulations.
- Failure of government to create incentives which attract new doctors to the specialty of pain management, replacing doctors who have left.
- Making the use of cash illegal when paying for medical care and services.
- Giving law enforcement agencies access to personal health information (PHI) collected by state agencies.
- Sharing PHI collected by state agencies with neighboring states.
- Restricting or limiting a patient’s access to their PHI collected by and shared with other states.
- Making it illegal to use the PHI collected by states, in civil or administrative actions taken against bad physician actors or other entities.
- Increased bureaucracy through physician record keeping and compliance requirements, without tax breaks offsetting the costs of collecting such data.
- State agencies who, either by design or due to lack of funding, fail to investigate bad physician actors who commit ethical or civil rights violations.
These are some of the new barriers to accessing healthcare, barriers because they allow bad actors to operate outside guidelines and standards of care, unchecked by the agencies designed to monitor physician practice and protect public interests. Together they create a new class of privilege which favors government and business over patient health and well being.
Doctors are also faced with shrinking medical reimbursement rates which do not keep pace with inflation, or the rising cost of services, medical equipment, labor and capital expenditures needed to operate in an increasingly technical industry. Is it any wonder that in some states, since 2010, 60% of practicing pain specialist have closed their practices and gone out of business? Physicians are scared out of their wits about how easily federal or state agencies can literally shut them down for weeks as they run records to investigate a claim which may or may not have merit. Small and large medical practices have no recourse available to them to protect day to day operations while such matters are investigated. With incomplete guidelines, designed only to reduce opiate related deaths, doctors are handicapped on treating the dozens of medical conditions using traditional standards of care. Fearful of government retaliation, providers have left the practice of pain management.
A similar situation arose in the mid 1980’s when obstetricians saw medical liability insurance rates sky rocket due to law suits filed by patients following rising death rates during birth. So many physicians left the practice of obstetrics and expecting mothers couldn’t find doctors to provide medical care. Government had to step in with tort reform and incentives to attract doctors back into obstetrics before the problems were resolved.
In response to government reforms doctors advertising as pain specialist have either quit taking in chronic pain patients or have taken such outrageous defensive postures that patients are compelled or coerced into signing away all rights they have, both civil and criminal, for any wrong doing by a physician.
Until citizens and physicians alike stand up and demand changes from our government, there will continue to be innocent victims in the ranks of both patients and doctors. Pray you are not counted among the unlucky few who, following an accident, injury or a newly diagnosed medical condition become a chronic pain patient or your acute pain needs are so great that the 90 MME per day dose of pain medication recommended by the CDC, can’t provide you with adequate pain relief.
While nearly every clinic has something to say about patient civil rights, HIPAA rights and ethical standards, little more than a token head nod is given to such concerns when the need really arises. Patients are exploited in some clinics because they don’t know, nor do they recognize, the concept of owning their own bodies and the rights afforded them under informed consent. Nor do they understand their rights as the payer for medical services. I have asked these questions as I sit in waiting rooms and only half of those I ask, know the answers to such questions. Overall, patients continue to believe that they will be treated fairly, honestly, with dignity and respect. The truth is, that’s no longer a guarantee as current government regulations pit provider interests against patient interests. Under such conflicting priorities patient are inevitably the losers as physicians can refuse treatment to a patient for any reason. The only action a patient can take is to file a complaint with a state medical association which has little to no incentive of hearing it.
Call an attorney about such issues and you’ll quickly learn that if a patient hasn’t suffered an injury, there is no recourse for addressing a failure to provide informed consent, nor is there any recourse for a doctor who uses coercion to manipulate patients into signing away a patient’s legal rights. The adage, “Buyer Beware” in healthcare takes on a whole new meaning under such consequences where life and death or the quality of life hang in the balance. If you’re not economically empowered to pursue such issues, your quality of life is meaningless, your ability to retain legal representation non-existent.
While much lip service is given to patient rights or fair and equal access, these terms are only relevant to those who actually have the economic power to purse them. Between government, healthcare and the legal system, the average person is powerless in such matters, with privilege and favor granted to all concerns except those of lower economic status. If you’re a chronic pain patient receiving opiates you could file a complaint with a state medical association, but rest assured, any complaint will be summarily dismissed as drug seeking behavior in today’s regulatory environment.
There are a mountain of barriers for chronic pain patients trying to access healthcare, not the least of which is bias and prejudice. Our government simply has no interest in seeing it removed or leveling the playing field.
Finally, with healthcare so steeped in science and law, the average person doesn’t know what questions to ask much less recognize when they have been exploited due to healthcare’s specialized nature. As I sit in the waiting rooms and talk with other patients, as many as half are unhappy with the services they receive or the care they are getting, but few can put into words why they feel that way. Some react aggressively and speak of suing the doctors, not realizing that they have no legal recourse when the patient contract they just signed, includes waivers releasing their rights to sue the doctor for any reason. When made aware of this fact, most don’t believe it because the language and wording in these documents cleverly hides the real intent. Patients just blindly sign the forms still believing their providers are guided by honest, ethical and moral standards.
Increasingly, doctors in their efforts to protect themselves from their perceived and real liabilities; have taken up defensive postures such as:
- Requiring patients to waive their civil and legal rights granted under federal and state statues.
- Requiring patients to agree to be audio and video recorded during office visits.
- Requiring patients to agree not to operate an automobile if prescribed opiates.
- Requiring patients to be available for spot exams and urinalysis with no more than twenty four hour notice, limiting a patient’s ability to travel away from home for work or personal business.
- Providing a form acknowledging informed consent, but in practice refusing to answer questions about patient treatment options, risks and benefits. If not refusing answers then in some cases flat out lying to patients with dismissive answers or half-truths.
- Requiring patients to sign a waiver giving doctors unilateral decision making authority without a patient’s participation in such decisions.
- Requiring a full medical work up on each office visit, sometimes as often as twice monthly, despite standards of care contrary to such practices.
- Refusing patients a copy of medical records, even for review while in the doctor’s office, or obstructing such efforts by telling patients records can’t be released without a doctor’s approval.
- Refusing to discuss results on lab tests and how such information is used in planning medical care.
- Making changes in medical treatment unilaterally without first consulting with or getting approval from the patient.
At some clinics when I have refused to sign such documents without first discussing my questions with the doctor, I’ve been told I can’t be seen by the doctor unless I first sign the forms. Such actions are clearly coercive and should be a clear and unmistakable violation that demands action by our government agencies, but to date I know of no actions taken by any agencies. Encouraged by such inaction, some clinics extend that coercion as a means of revenue generation by pushing unnecessary procedures. When some well informed patients challenge such efforts, I’ve seen doctors retaliate by reducing medication dosages as further coercion. Some arrogant professionals believe their judgment to be unquestionable, they too retaliate in an unethical manner. I’ve had patients tell me that a doctor has threatened to call police and have them removed from the office when all they were doing was asking questions about their medical care or objecting to having their treatment changed without thier consent or approval. Such acts should carry with them severe disciplinary consequences, but in most states filing a complaint with a state medical association results in no action at all, a clear sign of either protectionism or utter disregard for the welfare of patients.
My strong criticisms of government are not about what government has done to get the opiate crisis under control, but instead are about what government has failed to do in addressing the fallout created by the actions they’ve taken to date. In the war on opiates, states have created a patch work of regulations and guidelines which primarily remedy the states concerns and do little to nothing to address physician and patients concerns. Such oversights fail the obligations states have to both citizens and healthcare providers alike.