Tuesday, October 20, 2015

Weems Chronic Pain Treatment Policy

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