Should Americans live in fear? Should patients be denied pain control?

Everyone agrees the answers should be NO.

Yet, here we are. 

Another excellent view inside the clinical world from the KevinMD blog.

https://www.kevinmd.com/2023/07/the-persecution-of-pain-management-doctors.html

The persecution of pain management doctors

JULY 25, 2023

The call came in during a busy workday. My comprehensive primary care clinic had been built over a decade of hard work and had a general practice clinic staffed by a very capable former surgeon and several nurse practitioners, as well as a pain management program and an addiction treatment clinic. We also had several counselors on staff. I immediately recognized the voice on the other end of the line as a friend of mine who was a pain specialist. Her office was at the other end of the state from mine, but we had worked together off and on for over twelve years. She told me that the medical board had called her down and complained that she had some patients on opiate therapy at more than 90 MDE. She had argued that the CDC clearly meant the guidelines for primary care physicians, not specialists. They were not responsive to this argument and immediately suspended her medical license.

She and I had discussed the dangers of continuing to treat pain, knowing that the DEA wanted to make some examples, and several doctors in our state had suffered criminal charges. The complaints published about their practices left us bewildered. They had charged cash, treated patients under the age of fifty, and had patients that traveled long distances. Another was charged with complaints of his having treated people he knew (or should have known) suffered from addiction. They were also criticized that a percentage of their patients had criminal records, quoting a percentage. I wondered where the doctor could go to get accurate criminal record information. More importantly, when I checked the quoted percentage, it was lower than our state average. But more importantly, since when can a doctor not treat someone who has a criminal conviction? Finally, I noticed that the DEA was quoting morphine dose/milligram equivalents, leaving the press and the public with the impression that these were individual pills. I wrote a letter to the reporter trying to correct these misstatements but never saw a correction.

Then a third doctor was hit. She had prescribed Xanax to a patient in crisis at a McDonald’s parking lot. Not a crime, but then she panicked and lied about it when questioned by federal agents, allowing herself to fall victim to 18USC1001: lying to a federal agent. The first physician was 71 years old, pleaded guilty to one count of prescribing a Schedule IV medication, which was supposed to have a maximum term of five years in prison. But the government argued what it calls “relevant conduct,” at which they attribute any patient deaths as “related to” the prescriptions. The doctor was sentenced to 120 months in federal prison. The second doctor pleaded guilty to wrongfully prescribing alprazolam and was sentenced to four years in prison. Finally, the third doctor was sentenced, also for alprazolam. In this case, the government agreed that no prison time was necessary, but the judge felt that a message should be sent to physicians treating pain and sentenced her to three years.

These events were worrisome as none of the complaints listed are actually crimes. I had, in fact, taken hundreds of hours of CME in pain management and addiction, and no one had listed age, criminal history, or payment method as problems. My practice had set up very strict procedures and protocols to avoid diversion and monitor for signs of addiction. I had joined both the American Academy of Pain Medicine and the American Society of Addiction Medicine and was taking board review courses, as I find these to be excellent ways to stay up to date. I had even traveled to take in-person classes held by Harvard Medical School. Everyone in our practice who received controlled medications had counseling made available to them, and we would not accept a patient for opiate therapy unless they came to us already on opiates with a chronic pain diagnosis made and confirmed byother medical professionals and specialists. We did make an exception for patients with cancer, as oncologists were referring patients to us for maintenance treatment.

I searched my calendar to see how I could reschedule patients to help my friend keep her practice alive until she could retain counsel and defend herself to the board. While I was doing this, my receptionist told me that a sheriff’s deputy wanted to see me. A cold feeling came over me, and I woodenly shook his hand and accepted the envelope he handed me. Inside was my emergency order of suspension from the medical board. It turned out that a disgruntled former employee had called an insurance company pretending to be a patient and had complained that I was “treating addicts.” The insurance investigated and found that some patients had died within thirty days of being treated by us. Since we saw all of our patients every thirty days, this would be the case no matter why they had died. It turns out that today, any patient that dies while taking opiates is listed as an “opiate-associated” death, even if they die in hospice or by suicide. I even had a patient who died in police custody, twenty hours after last taking his medications and after being denied proper medical care. The jail told his family he had died of an overdose, despite the coroner’s finding on autopsy that he died from a cardiac condition.

The insurance company investigation found that our treatment had been reasonable but felt they had to notify the medical board. The medical board felt they had to issue an emergency order of suspension without giving me a chance to defend my practice. When I finally went in front of them, the suspension of my license was lifted, and I thought the ordeal was over. Instead, law enforcement officers went on the news to say that the board had been too easy on me, and I was indicted that same day. I did not plead guilty but took it to trial. The government wanted to give me twenty to life for the patient who died in police custody. I took the stand in my defense and tried to help the jury understand the complications of medical practice and the risks and benefits of opiate therapy. I explained that I was certified to treat addiction, and that while my patients on opiate therapy did not have addiction, even if they did, the benefits of treatment could outweigh the risks. The government’s expert testified that MRIs were not objective, that a veteran treated with methadone for pain meant he had addiction, that a man with a hand crushed so badly that a finger was pulled off did not have “real” pain and should not have been treated. The fact that I had cut him back from three opiates to two and from two benzodiazepines to one on that first visit went right over the jury’s heads, as well as the fact that I had reduced his opiates sixty days and his benzodiazepines thirty days before his death.

The government’s expert testified that when my chart notes referenced my concern about the potential for addiction, that this was absolute proof that the patient had addiction. The prosecutor told the jury in closing that we only accepted patients already on opiates because it was easier to get them addicted. None of these statements are true, but I was shocked to find that you can’t use the textbook in your defense. You also cannot use the content of your CME in your defense. You have to rely on experts, most of whom are now too terrified to testify for the defense, and the government can have their witness make statements completely contrary to the scientific practice of medicine. I was found not responsible for the death but convicted for treating the patient at all, as I had placed him “at risk” of addiction. I was also convicted for treating the veteran who had been prescribed methadone, despite him testifying that I was a compassionate doctor who had always tried to help him reduce the opiate medications he came to me on. I am waiting for sentencing and looking at up to twenty years in prison. If I could offer any word of advice, it would be for all primary care physicians to stop treating pain until this insanity is rectified, as it is impossible to educate a jury in a week. And there is no limit to what the government can say to get a conviction. They are not bound by truth or science. Also, if you come under prosecution, hire only a health care prosecution specialized attorney. Do not trust that any other attorney will understand things well enough to adequately defend you.

Dr. L. Joseph Parker is a research physician in Texarkana, Arkansas. He received his medical degree from Mayo Clinic College of Medicine and Science and has been in practice for more than 20 years.