By R Carter
In Part 1 I covered the demographics of those who participated in this poll and laid out how responses for the rest of the poll would compare answers from the two major groups, healthcare professional’s and patients.
In Part 2 I provide responses for questions asked about medical boards. The purpose was to see how well healthcare professionals vs patients understand how medical boards operate. To get views from patrons for what they believe medical boards should be doing while supporting the public and regulating physician practice.
The DEA’s power over physician practice is limited, even more limited than most know. The DEA cannot by law interfere with the actual practice of medicine and when it comes to controlled substances, it’s limited for the most part to issues of diversion. So when the Department of Justice, through the DEA, brings charges against a physician for prescribing outside the bounds of “accepted medical practice” they must enlist a state medical board or another physician to make such determinations.
The DEA also works with local law enforcement and state medical boards to bring charges, from press releases I’ve read, those charges are both rational and reasonable most of the time. Yet there are examples where charges brought against a physician stretches the limits of believably.
For example when an indictment is published you may read facts such as 800,000 pills were dispensed over a six month period. This sounds like a lot and I assume that’s the point to publishing it this way. But when you work the numbers backwards, as I do below, the charges don’t always make sense, giving every appearance of being excessive.
Most pain management physicians have an advanced nurse practitioner (ANP) or two working with them. In our example we’ll use one doctor and two ANP’s, each can see 30 patients a day. A typical chronic pain patient takes two types of medication. A long acting tablet lasting 12 hours and short acting one lasting 3-4 hours. In this example I’ll use two 12 hour tablets per day and 4 short acting tablets per day. That comes out to 180 tablets per month for each patient in our example.
Not all patients require pain medication, some don’t require it every day and others may require more. So I’m reducing the number of patients per day treated to 25 per prescriber. I’ll assume these providers only see patient prescribed opioids four days a week, further reducing the total possible to 16 prescribing days per month. That comes out to 1,200 patients per month seen by all prescribers.
With each patient being prescribed 180 tablets a month, for the two medications, that’s 216,000 tablets per month. Next multiply that by six months for 1,296,000 pills. So a physician charged with over prescribing based on 800,000 pills over 6 months, is well below this reasonable example.
So how does law enforcement make such charges stick? We don’t know, because there are facts which are not mentioned in the DOJ press releases. Those omissions could change how we calculate our example, but with how they currently report these events, it sometimes looks suspicious. Many physicians in just this type of scenario have claimed they’re innocence.
After the Washington Post released the DEA pill data awarded in their law suit, I obtained a copy and searched for examples of what I would consider excessive prescribing. Some of the worst prescribed enough medication to meet the example above for an entire community of people or an their entire county for the state they were in. But it was not as wide spread as we have been led to believe. As usual there only a few bad apples in the bunch.
For those who prescribed excessive amounts, this is a clear violation of the controlled substance act and some were likely diverting these medications to sources outside the practice of medicine.
If you’d like to use the example above, on how to calculate total number of pills for a clinic, physician or pharmacy in your area, follow this link to a report generator which has the DEA pill data for years 2006 – 2012. The report lists numbers by monthly scripts based on MME averages of 50 up through 120 MME per day. If you need a calculator to convert MME to pills use this link to find one.
Medical boards operate under the jurisdiction of the State Governors Office. For this reason and depending on the infraction, they are not required to have hearings on actions taken by the medical board and no judge presides over the process. This gives medical boards a great deal of latitude when taking action. Some boards have an attorney on the board who consults with outside legal counsel when taking action against a physician.
So we asked patrons if they believed state medical boards had circumvented physician rights to due process by the manner in which they operate. 84.7% answered yes.
Next we asked, do you believe State Medical Boards need greater oversight and accountability? 86.7% answered yes, more importantly, 100% of the healthcare professionals answered yes to this question.
We asked what types of oversight are needed? Patrons were allowed to select up to three answers, and suggest one if they wanted. The most popular answer was to have a citizen representative on the medical board, with 89% of respondents choosing this answer followed by medical board meetings open to the general public at 50%.
We asked patrons to select who they thought was the best mix of professional types to serve on a medical board. Respondents were allowed to choose up to four answers. This included citizen representative, physician, attorney and public health physician. Response ran from 1.7% wanting citizen reps only, up through 24.7% wanting physicians only. The remaining answers were an even mix from all four types with the largest group being physician, attorney, public health and citizen rep. at 43%.
Since board memberships are by appointment from the Governor’s Office and therefore is influenced by politics, we asked patrons if they would support changing state law to make such appointments an elected position. 74.6% answered Yes, they would support such a change, giving the public a measure of control over healthcare regulations.
With state and federal legislators passing laws regarding prescribing, medical boards which pass regulations that carry the weight of laws, we asked patrons if every state medical board should have a pain specialist. Overwhelmingly 89.5% answered in the affirmative.
Since most hospitals, clinics and physicians operate as a private enterprises, they are afforded more protection on how they conduct the business healthcare. Smaller independent practices often take liberties with patients a larger institution wouldn’t.
Such actions lead to conflicts between patient and provider with the provider usually winning hands down. In poorer communities where a patient population is less educated, more chronic pain patients are unaware of when they are taken advantage of. This may include being forced to repeat procedures which were previously tried and failed. Or maybe repeat procedures are done so the provider has their own record of that procedure. Maybe doing so makes the time and effort spent on complicated patients more profitable. Other times procedures are about medical legal or insurer compliance issues. In any case they’re not always explained to patients who are ultimately responsible for paying the cost.
Standards of care are usually broad and general, allowing physicians a good deal of latitude when treating patients. But with regards to opioid prescribing, this freedom no longer exists because of caps and limits. Most patients have no recourse for addressing such issues. Under existing laws and regulations, a patient taking opioids can no longer simply move on to another provider when they are dissatisfied with the services received. Not without incurring a treatment penalty or the loss of a treatment altogether. For such individuals there are few options for filing a grievance. State medical boards have failed at convincing the public grievances will remain confidential, so chronic pain patients are naturally concerned about retaliation and will not report a grievance when they can’t easily transfer to another provider.
Ignored by their legislators, their insurance providers, Medicare and Medicaid, chronic pain patients feel like lepers, cast out, when the only thing they are guilty of is being a chronic pain patient. Under the microscope of opioid hysteria, this group relies on social media platforms such as this to air their grievances and search for answers.
We asked patrons how Medical Boards could better protect their interests in this new era of treating chronic pain. Surprisingly the largest response from both patients and healthcare professionals was to do nothing at all, with 51% responding in this manner. Followed by 30% wanting to see more done by medical boards to ensure general patient rights and the last most popular response was to have better arbitration for ethical issues, specifically unethical behavior with 18% responding with this answer.
Having heard from many on this blog, I personally believe the reason for such a high response, 51% wanting to do nothing, is because this group believes they are helpless, victims of a tragedy they did not create, defeated because they’ve tried everything they know only to be ignored.
We asked patrons to rate whether actions taken by law enforcement and medical boards have improved or lowered the quality of medical care. 95% said the actions taken to date on addressing chronic pain have lowered their quality of care. Most complain offline that with all the emphasis placed on addiction and overdose, those who are compliant in their medication use, are no better than the addicts our government is trying to rid itself of.
Chronic pain patients view themselves as 3rd and 4th class citizens with regards to having a choice in their medical care. Victims of regulation aimed at them to prevent a drug problem which occurs not because of over prescribing but from a criminal element they are not a part of. Pressed from medical boards, state and federal laws, insurance providers, physicians and pharmacies, but worst yet, ignored by their elected representatives as though they were aliens in this country.
We asked patrons to suggest what actions should be taken to return them to the same rights which all patients have. 45.8% answered with needing to create a patient bill of rights. 20.7% want to see arbitration services from the medical board. 12.2% want regulations to ensure they cannot be refused care from a provider or insurer simply because the only treatment left is an opioid. 12% just want government out of healthcare decision making. The remaining 9.4% want to be reimbursed or compensated when refused medical care because they lost jobs or been denied care, all of which has created more debt and lower quality of life.
The next question was pretty much a no brainer with more than 90% of respondents being chronic pain patients. We asked how many support the use of fixed caps and limits imposed by medical boards. 100% answered they do not support these regulations. If the reader wants a better understand for why respondents answer this way then follow this link to the survey results on the consequences for forced tapering and termination of medication. The stresses placed on families from loss of income and the availability of a parent or spouse who’s afflicted with these outcomes is quite severe.
Some pain specialty clinics have stopped offering opioids for the treatment of chronic pain conditions, driven out of this area over fears of prosecution when following the standards of care. Others have left this part of medical care because they know they can’t help patients under the current regulations which limit the amounts which can be prescribed.
Others continue to advertise pain management services but when contacted you must answer several screening questions. If a patient is taking opioids, the clinic will state they do not prescribe opioids and therefore can’t treat the patient.
Add these to the number of clinics which have out of business and the number of clinics to choose from are severely limited. Most patients now drive upwards of 50-150 miles to see a provider and the same to fill a script. Wait times in the offices which remain are long, sometimes as much as 3-4 hours. All of these consequences for how this issue is now managed, places a greater burden on patients and employers who hire these individuals. Creating a new class of disenfranchised American’s who’s only mistake was to get sick or injured.
We asked patrons if they thought clinics specializing in pain management should be allowed to exclude opioid prescribing from the services they offer. 51% said medical boards should ensure specialty clinics provide full services for pain management. Another 38.7% included the previous answer plus indicating that such allowances do not serve the best interest of the public, which is after all the primary mandate of a medical board.
We asked patrons how medical boards could best promote safe medical care for chronic pain patients. 64.9% said less regulation by allowing doctors to use their own judgement, 1.7% thought more regulation was needed by addressing opioid use disorder, acute and chronic pain as separate issues. 23.6% said adopting specific regulation for opioid use disorder and removing regulations on treating acute and chronic pain. And 8.8% though regulations should be generalized guidelines, avoiding specific regulations for specific medical conditions or treatment modalities.
We asked patrons to rate medical board guidelines in their state for acute and chronic pain. 45.4% responded they were not sure what the guidelines were in their state. 34.8% responded that guidelines are geared towards acute pain and opiate naïve patients. 15.1% responded their state has separate guidelines for acute and chronic pain. 4.7% responded they believe their state’s guidelines were generally well balanced for acute and chronic pain.
For his question healthcare providers were more informed, with only 2.9% of the group not knowing what the guidelines were. Patients were the least informed, 42.5% not know what the guidelines were for their state.
For patrons who answered the previous question as not knowing the regulations in their state, we asked the 211 in this group, if medical boards should have separate guidelines for acute and chronic pain. 97.7% answer yes, 1.9% answered no and 10.2% were uncertain.
We asked patrons if they believed chronic pain guidelines should incorporate a dosing component to account for the development of tolerance when prescribing long term, that is more than one year. 91.7% of patrons responded they agreed with this while 5.2% did not and 3.4% were uncertain.
Regarding the CDC guidelines for primary care providers, which were based on acute pain and opiate naïve patients, state medical boards adopted the same or something close to it, when writing guidelines for all physicians in a state. Prior to this time, physicians followed prescribing literature issued by the FDA. Such literature was tailored to a specific product rather than a product classification. It followed the traditional scientific method of calculating dosages based on body weight, which includes starting dosages new patients and upper limits for individual taking medication over extended periods. FDA literature addressed preexisting conditions, considerations for other drugs used in conjunction with a product, as well as warnings and symptoms for overdose, including lethal dose limits.
The prescribing literature from the FDA easily has 10,000 times more information than that provided in any medical board guideline and far more than what was provided by the CDC. This is because FDA literature is tailored to treating pain rather than trying second hand, to prevent addiction as the CDC guidelines do.
Government and public health could have easily lobbied the FDA for better prescribing literature, to address both addiction and abuse, but instead our system was sabotaged by opting for direct control of physician practice through an agency whose mandate is for treating infectious disease processes, not routine medical care. With such actions is it any wonder legitimate chronic pain patients feel targeted for disposal?
We asked patrons if they would prefer to see prescribing guidelines for pain management return to using FDA guidelines which allows doctors to treat based on body weight, age, gender, other medical conditions as well as concurrent use of other medication types. 63% answered yes, 15.7% answered no and 21.3% were uncertain.
In Part 3 of this series we’ll look at how patrons responded to questions about law enforcement’s role and how it has impacted physicians and the chronic pain community.