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| Dr. Patrick Conrad |
From Weems Memorial Hospital October Newsletter:
An Open Letter from Dr. Patrick Conrad, Weems Emergency Department Director
For several years
questions from the community and local elected officials have continued
regarding the ability of the Weems clinics to treat chronic pain with
controlled prescriptions. These are
valid concerns that deserve some update and clarification as we work to improve
our regional care.
Chronic pain is real,
it is distressing to patients and their families, and also to the physicians
who care for them. In the classic
tradition, treatment decisions would be left up to the attending physician and
the patient, both of whom would rely on the clinical presentation and the
doctor’s best judgment.
Candidly, those days
are gone in a tangle of lawyers and legislation that cannot be ignored. It is also true that there is a nationally a
serious epidemic of prescription medication abuse from which we are not immune.
The examination of
chronic narcotic usage has both ethical and legal components. Ethically, the physician is obligated to
provide the best possible care, including the alleviation of pain and
suffering; that does not include the unnecessary (!) physical or psychological
habituation of a patient to addictive medications and their deleterious side
effects. Competent practicing physicians
will confirm that the best medical care often requires denying what a patient
requests in order to protect that patient’s best interests.
The legal side is more complex, and in some instances trumps the ethical obligations.
We are obliged to
start with a common definition of chronic pain, as given by Florida Statute
459.0137: “Chronic nonmalignant pain”
means pain unrelated to cancer which persists beyond the usual course of disease
or the injury that is the cause of the pain or more than 90 days after
surgery.” This does not prohibit short-term, small amounts of prescription
narcotics for acute injuries, or pain control in terminal cancer patients. The restrictions described below apply to the
ongoing prescribing of addictive medications for non-cancer patients. And yes, many compassionate primary care
doctors had for years prescribed daily narcotics to the elderly for chronic
arthritis and other degenerative conditions.
Bluntly, those days
are gone. According to the definition
above, any physician so prescribing will be regarded by the state as a
“controlled substance prescribing practitioner pursuant to Florida Statute
456.4 (“Controlled substance prescribing”), and must so designate himself with
the state. Such a designation requires
“...ensuring compliance with the following data collection and reporting
requirements” which include “ ... in writing, on a quarterly basis, all new and
repeat patients seen and treated at the clinic who are prescribed controlled
substance medications for the treatment of chronic, nonmalignant pain”; those
discharged due to drug abuse or diversion; and those “patients treated at the
pain clinic whose domicile is located somewhere other than in this state.” Additionally, each patient receiving chronic
narcotics must have a written treatment plan with objectives; a signed
controlled substance agreement with the patient; documentation of having
discussed abuse and addiction risks with patient. The state is also monitoring
to see that the patient is seen “at no more than 3 month intervals” (source
Hall Render Killian Heath & Lyman, PC), and that “unless the physician is
board-certified or -eligible in pain management, patients with drug abuse symptoms
must be immediately referred to a board-certified pain management physician or
an addiction medicine specialist.”
But surely a
physician who means well can convincingly argue his case? Not according to Florida Statute 458.331,
Grounds for disciplinary action: “...it
shall be legally presumed that prescribing ... all controlled substances,
inappropriately or in excessive or inappropriate quantities is not in the best
interest of the patient and is not in the course of the physician’s
professional practice, without regard to his or her intent” (emphasis
added). Penalties for being found in
violation of this regulation may result in substantial fines and license
suspension of 6 months, 1 year, or complete revocation.
Is the state really
being so hard-nosed in their prosecution of these violations? Florida Attorney General Pam Bondi said on
9/26/14: “In 2010, 98 of the top 100
oxycodone pill dispensing physicians nationally resided in Florida. In 2011, after the passage of HB 7095, only
13 of the top 100 resided in Florida, and by the end of 2012, not one Florida
doctor appeared on the top 100 list.”
This statement had been previously confirmed by the DEA on 4/5/13.
The DEA also noted
that from 2011 to 2013, “42 physicians lost their DEA registrations through the
issuance of Immediate Suspension Orders (ISO).
The ISO suspended the DEA registrant’s ability to handle controlled
substances in Schedules II – V. Also
approximately 61 more DEA registrations were voluntarily surrendered by
physicians following an official visit from the DEA (and)... 38 pain clinics
were closed due to the investigative efforts of the Tactical Diversion Squad”,
according to the DEA’s official website.
Where therefore do
the Weems clinics and their clinicians stand? Several years ago Franklin County had a large,
very serious prescription drug addiction and diversion problem, to which I can
personally attest from working in our emergency department. Today that problem is significantly smaller,
if no less harmful for those still affected.
Ethically, we dare not open the gates to a resurgence of a larger scale
affliction that will be harmful to patients.
Legally and
professionally, our physicians and clinics so urgently needed by our local
patients cannot be put at very real risk by running afoul of the state’s
initiatives to curb this problem. While
it may be difficult to educate the public, it is imperative that we honestly
explain the delivery of their best, compassionate care while protecting our
ability to actually deliver it.
Please contact me at
any time if I may be of assistance in this matter.
Respectfully,
Patrick
Conrad, MD
Weems
Emergency
Department
Director
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