How Not to Run a Pain Clinic

Attorney takes us on an inspection

by Ronald W. Chapman II

My associate and I pulled into the crumbling parking lot. It was only 9:30 a.m., but the parking lot was nearly filled to capacity with cars and people milling about and walking in and out of the old building, its signage barely detectable.

I had been retained to conduct an inspection of another medical practice under federal investigation for issuing thousands of doses of oxycodone "for other than a legitimate medical purpose." The entrance to the pharmacy on the first floor of the building was manned by a security guard, and neon-colored flyers littered the surrounding walls.

The pharmacist had taped up several notices about forged prescriptions, Medicare coverage, and cash price lists for the most prescribed controlled substances. This was not a great first impression. We waited for the elevator to the third floor, along with a half-dozen people in their mid-20s, early-30s.

We stepped off the elevator and headed to Suite 322, and as expected, so did everyone else. Several people were seated on the floor in the hallway outside the medical suite and an older woman in a wheelchair was parked against the wall. The waiting room inside was standing room only.

In addition to the standard office waiting room chairs, several old folding chairs had also been brought in. There were no magazines, no side tables, just a dusty floor lamp and some random medical leaflets inside a magazine rack bolted to the wall.

It was clear that everyone had run out of patience, people were complaining and seemed to be competing for an award for who had been waiting the longest. The TV in the corner of the room was unbelievably loud and still held the attention of only a few.

We stood in line at the reception counter behind a man demanding to know when two of his patients back there were going to be out. The receptionist had no answer for him. The receptionist did not even look at me or my associate, she just handed me a new patient intake form and told me to have a seat.

When I gave her my name, however, she shot out of her chair, mustered a smile and apologized, and brought us back to an empty examination room. I found that someone had already pulled a couple dozen patient charts and set up a card table in the examination room for us.

The receptionist offered us coffee and said the doctor would be in to meet with us as soon as she could. Right away, we noticed the examination room was barren. There was no exam table, scale, blood pressure cuff, or tongue depressors, and no educational or anatomical charts on the walls.

Criminal?

We sat down and started to review the patient charts while we waited for the opportunity to interview our client regarding patient care and practice policies. When the doctor arrived for her interview, she started with her background and education -- she had recently been hired to work locum tenens by the owner of the practice and had signed on for 6 months.

This doctor had been at the practice for only 2 months, but she had already discovered that the majority of the patient population were receiving controlled substances. We asked why the charts offered little to no insight as to the patients' medical history, conditions, or treatment plans. She explained that most of the patients suffered from lower back or neck pain, and without insurance, they couldn't afford expensive radiology and lab tests.

She further explained that, to make the situation worse, the patients complain loudly and threaten to never come back if there is any attempt to "cut down" pain medications. After our review of many patient records, it was clear that a federal investigation into the practices of over-prescribing of controlled substances was not entirely without merit.

Chart after chart, the patients were either on oxycodone 30 mg or hydrocodone 10/325 mg, along with a benzodiazepine. When asked if she was aware that these medications, in combination, were potentially hazardous, she confidently reminded me that pain was the fifth vital sign and that most chronic pain patients suffer from anxiety.

Defensively, she offered that she was new to the practice and it was the other doctor that prescribed these medications; she was only filling in and was not comfortable changing the treatment for another doctor's patients. She said she had brought some of her concerns to the practice owner and that the owner had assured her that a compliance program, including urinalysis tests and prescription drug monitoring, was on the way.

Unfortunately, this scenario is not fiction.

The Rx

Tipped off by the outdated view of pain management practices and lack of compliance, we knew that re-education and a compliance program would be the right prescription for this physician. Like many who share her circumstances, the doctor was not a criminal, just wildly misinformed and on the verge of a federal indictment.

The phrase "pill mill" has invaded the common medical lexicon as a symbol of the Florida pain clinics in the early 2000s where prescriptions for high strength opiates were handed out carelessly in exchange for cash. With a few very limited exceptions, that does not exist anymore.

DEA enforcement and extremely high sentences for drug dealing physicians have all but shut down what we envision when we hear the words "pill mill." It has been replaced by a string of prosecutions against physicians who are practicing in an antiquated or negligent manner and are easily duped by the modern drug dealers -- patient recruiters.

Indeed, physicians who face disciplinary action are disproportionately older, male, lack board certification, and work in general practice. Studies of physicians who exhibit careless prescribing habits yield similar results.

As an attorney working on the front lines of the "opioid epidemic," the problem is clear. Finding a physician who deliberately intends to criminally traffic in narcotics is a rare occurrence, but should be punished accordingly. However, the bulk of physicians contributing to the opioid epidemic are overworked, under-trained physicians who could benefit from increased education and training.

Draconian Hammer Time

To a hammer, everything looks like a nail. Federal prosecutors have recently received increased funding to purchase more hammers -- a lot of hammers. In March 2018, Congress authorized $27 billion in funding to combat the opioid epidemic. The largest line item in the 2018 budget was $15.6 billion in law enforcement funding.

It is disappointing to see that virtually none of this additional funding will be spent on solving the real problem, which is physician education. Resources should be poured into programs like the American Medical Association's "End the Epidemic Program” and state programs designed to enhance provider education.

Instead, regulators have focused on draconian policies and statutes designed to limit prescribing practices. Rather than utilizing alternative enforcement mechanisms, regulators have primarily used two methods to combat improper prescribing: licensure revocation and prosecution. Re-education is not on the menu.

Fueled by the 2016 CDC guidelines, nearly every state has issued opioid prescribing guidelines, and some have taken the drastic step of instituting prescribing limits. Taking away a provider's freedom to prescribe is not the answer and will lead to decreased access to care.

If a state trusts a physician with a medical license, it must also trust him or her to exercise good judgment and good faith in the course of treating legitimate patients. Unfortunately, physicians are increasingly afraid to exercise their judgment as wave after wave of prescribing guidelines, statutes, and rules make compliance increasingly difficult. Increased provider education and a restoration of trust in the profession of medicine is the only way to solve this opioid epidemic.

Ronald W. Chapman II, Esq., is a shareholder at Chapman Law Group, a multistate healthcare law firm. He is a defense attorney focusing on healthcare fraud and physician over-prescribing cases as well as related OIG and DEA administrative proceedings. He is a former U.S. Marine Corps judge advocate and was previously deployed to Afghanistan in support of Operation Enduring Freedom.

Comments

True about 'education' IF the education is legitimate, but so much of what has been passed off as gospel/dogma regarding the pharmacology of pain medications, but is not free from the taint of political agendas now, any more than it was free from the taint of pharmaceutical companies in the past. 

I find it interesting that the fundamental principles of pharmacokinetics are imagined to change just because the item requires a blue color of paper for the prescription pad. Yes, the social factors, abuse potential, and all sorts of other things DO change, and we MUST consider those for patient safety, but when the 'education' program becomes tainted with irrationality presented as science, don't blame some of us for being skeptical. 

Unfortunately, quotas and agendas and appearances are often the driving forces that overwhelm quality patient care, from both prescriber and 'regulator' standpoints. 

Yes, the practice example is terrible as illustrated in the article, but those of us who are actually trying to do the right thing for patients live in fear of being caught up in the maze of regulations set up to ensnare the pill-mill types. I don't see any other areas of health care where the dismissal of individualized care, and the expectation of lock-step clinical agreement, are so high.

Andrew Johnstone

I am a full-time employed defense med-mal paralegal for over 22 years at this position in this firm. I also happen to be a chronic pain patient as a result of failed back surgery x 2 @ L5-S1, Cystic Fibrosis, abdominal adhesions, CRPS, asthma, OA and a mind-dullingly long list of others. I am a compliant patient at a pain clinic for about 18 years, with the same doctors, until recently, when my anesthesiologist/physician suddenly retired and the name of the clinic changed, along with a "new" doctor from a different city. I have never been informed by the clinic that my physician "retired." The physician now in charge of my care immediately was aggressive and defensive, his military training readily apparent. I was told in no uncertain terms that I must: (1) stop the 1 mg Klonopin at bedtime, (2) would be prescribed 1/2 the ER opioid amount for the next month, and (3) would have that amount cut in 1/2 the subsequent month. There was NO compassion, nor was there any empathy. He didn't know me from Adam's housecat, however, I was treated as if I had walked in from the street. As a direct result, my heart rate increased as well as my blood pressure. I went through weeks of not sleeping more than 15 minutes at the time, and I began experiencing myoclonic seizure type movements of my knees to my chest, beginning at dusk and extending throughout the night. As of May 1, 2019, it has been 8 months since my first appointment with this man. Today, I attempted to have my opioid medication filled, since it was last filled on April 1, 2019. That did not occur due to the fact that he wrote "do not fill until May 4, 2019" on the prescription. My pharmacist urged me to call the clinic and explain that I was going to be without medication for 2 days because of this notation, and I was told she would "vouch" for me. Amazing in today's climate. I called and was told he was leaving to go out of town, and my call would not be returned for several days. People who are homeless and without insurance are afforded better care. Angry? Yes I am. Withdrawals - here we go again. Yet I must be present at work during the upcoming withdrawal period. I have a family reliant upon my income as well as health insurance benefits. I may not be the most eloquent of writers but I can tell you all, I am angry and very dissatisfied with my non-treatment from this clinic. It "looks" like a competent clinic, containing all the elements that are missing from the article above - except there is no doctor/patient relationship. First, do no harm. Not at this clinic.

It’s very sad for patients such as myself who really need the medications to control pain and we are being placed in a position where we don’t know who to turn to. Personally I have gotten worse because of doctors pushing Anti-depression medications and I’ve been used like a guinie pig and have more problems today because of all the changes “calling trial and error “ including heart rate problems where it landed me in the ER a few times with a heart beat over 150 and one smart doctor told me I was going through withdrawals from various anti depressants when I should have been warned to stop gradually instead of hopping from one anti depressant to another. until the right anti depressant starts helping. So far I’ve gone from full time therapist to a chronic pain sufferer every single day. I am more depressed now than I’ve ever been and a really have chronic pain where my pain really needs to be managed daily instead of pushing me to to take more anti-depressions. trial and error.? This is rediculous, especially when I’ve never abused medications in my life but being in pain all day can not make a person better or healthier. It is an epidemic but by God that’s what doctors are trained and should use proper judgement and distinguish between pain sufferers and abusers I understand that doctors are afraid, over stressed and can’t seem to distinguish between abusers vs. sufferers such as myself who need the pain medication to normally function every day. It’s really getting out of hand and I’m only one voice that perhaps will be heard and the appropriate treatment plan will be inforced by Doctors who do good practice. No person should suffer like I have every single day where I have to go through such agony not to mention how it has effected me and my family.
Patients like myself don’t have to be afraid, or pay because some rich kid or celebrity is abusing the system.
Somehow this has to be fixed. I should’nt be afraid or suffer every day because a Doctor is afraid to prescribe pain medications for those who reall need it. That’s unheard of.
I hope this will somehow be solved. But as of now I’ve completely lost faith in the medical system set in place.
So what now? Who do we turn to if not your own doctor who’s supposedly there to make you feel better but not worse like I’ve been this past year.
This is very very sad and disappointing.
Thank you for allowing me to speak up.
Sincerely,
Anna Babayan

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