The distressed chronic pain practitioner is nothing new. A minority of physicians have, throughout time, been willing to sell prescriptions for controlled substances without bothering to obtain a history and work up the patient’s complaint, perform a physical exam, arrive at a proper diagnosis, utilize testing or consultation, chose a rational treatment plan or properly monitor their patients. As a board investigator and private consultant, I have conducted more than 1,000 reviews of such dangerous practices.
Many experts in the fields of drug diversion, addiction medicine and chronic pain medicine state the recent development and mass marketing of high-dosage “long acting” CII (schedule two) narcotics has created new exploitative opportunities for drug abusers and diverters. Because the majority of chronic pain practitioners are well educated, compassionate, conscientious and make substantial efforts to minimize drug abuse and diversion, the problem must lie elsewhere — and in reality, it does.
Enter the distressed chronic pain practitioner. These are problematic physicians or other prescribing providers who, through errors of omission or commission, endanger patients or society. Many such errors are related to controlled substance prescribing, but many more are errors of a more fundamental nature.
A number of common themes often surface when one studies the distressed chronic pain practitioner. In most situations, although the practitioners involved are self-declared experts in chronic pain medicine, they usually have no formal training in chronic pain medicine or any history of studying under a qualified mentor in a prolonged clinical fashion. Many distressed chronic pain practitioners lack any sort of comprehensive CME participation in recognized chronic pain educational programs, do not belong to professional pain treatment organizations and do not read recognized current textbooks or journals regarding chronic pain medicine. It appears that in a large number of cases, their main source of chronic pain diagnostic and treatment information is limited to what is supplied by pharmaceutical industry representatives and their patients. Another more common trait of those who have recently declared themselves to be chronic pain specialists is they frequently have failed to flourish in the specialty of medicine in which they were formally trained. Factors contributing to these failures may be related to professional incompetency, personality problems, ethical problems, organic cognitive impairment, poor business judgments, psychiatric issues or ongoing substance abuse.
Twenty years ago, an otherwise failing physician could be kept afloat economically by “assisting” in a few major surgical procedures each week. Also, without competition from midlevel providers, there was more plentiful work for distressed physicians in underserved geographical regions, governmental positions and in group practices where their shortcomings were tolerated as long as they limited their practices to simple cases.
The current economic outlook for a distressed physician is more bleak. Hospital privileges, insurance panels, liability companies and governmental positions now scrutinize providers to a degree that eliminates many distressed practitioners’ economic options. These economic bars to practice are still separate from those of medical regulatory boards and the Drug Enforcement Administration (DEA). In fact, it is this separation that enables many distressed practitioners to possess the two critical necessities for opening up a self-declared specialty practice in chronic pain medicine: a valid state, provincial or territorial license and a current DEA registration number.
It is more common to encounter practitioners who have transformed themselves into self-declared chronic pain specialists who have been fired by an employer; lost their hospital privileges; been forced out of group practices; are not accepted to bill under Medicare, Medicaid or private insurance companies; been refused entry into the military or other government positions; or who cannot or will not purchase medical liability insurance. These poorly qualified pain specialists are frequently responsible for harm to their patients and society at large. The case presentation below is a typical example.
EXAMPLE: SELF-DECLARED CHRONIC PAIN SPECIALIST
A 55-year-old OB-GYN M.D. closed her practice and filed for bankruptcy after several serious medical malpractice cases were settled out of court. Two months later this physician moved to a remote rural town, opened a new practice and declared herself a “board-certified chronic pain specialist.” In fact, her only board certification was in OBGYN. She advertised in the local papers and soon developed a large chronic pain practice that attracted patients from well over 100 miles away. Within a few weeks of opening her practice, the gossip around town was the physician would collect $50 for each controlled substance prescription she wrote. This doctor saw an average of 60 patients per day, Monday through Saturday. A concerned local E.R. physician complained to the medical board that the physician’s patients were presenting to the emergency room with life-threatening signs of drug overdose. The medical board had the case for approximately one year, but took no action. Finally, undercover law enforcement agents documented the physician was not taking histories, performing exams, ordering lab tests or other studies or consultations and was charging $75 per prescription. Shortly thereafter, the doctor’s practice was closed by law enforcement agents. Several patients died as a result of accidental drug overdoses prescribed by this physician, and charges were brought against her for trading prescriptions for sexual favors from patients. It should be noted this physician had no training or interest in learning about pain medicine. Estimates from law enforcement are she prescribed well in excess of 10,000 doses of CII controlled substances per day, six days a week. The amounts of CIII (schedule three) substances prescribed were even larger, but more difficult to estimate, as many of these were phone prescriptions with multiple refills to pharmacies in at least two other states.
Interviews revealed this physician opened up a chronic pain medicine practice because she needed money quickly. She also admitted to having a deep need to “finally have a successful practice” and enjoyed working with “patients who really depended on me for help.” She repeatedly stated, “I have no responsibility for what my patients do with their pain medicines. I am not a cop.” She dismissed her lack of histories, exams, urine testing, other diagnostic procedures, any treatments other than controlled substances, informed consent, treatment contract, and specialty consultations as either completely irrelevant or as impossible to do because she had “way too many patients to see and help out each day.” After law enforcement raided and closed the doctor’s practice, the state medical board suspended her license pending further investigation. She has been officially charged with manslaughter, prescribing violations and sexual crimes against patients. Confidential interviews with the doctor’s local colleagues revealed that all of them knew she was running a “drug mill” and could not believe the medical board took so long to take action.
Although I serve as a consultant in helping problem practitioners, the aforementioned physician is probably not a good candidate for many reasons. Her interest in and knowledge of general outpatient medicine, pharmacology and chronic pain medicine was minimal. She showed no desire to learn about how to properly diagnose, treat and monitor chronic pain patients. In addition, this physician’s track record is replete with poor medical judgments and even poorer ethical decisionmaking. It is highly unlikely she would respond favorably.
Another new problem category is composed of midlevel providers, nurse practitioners and physician assistants who are usually employed by busy chronic pain practices. Again, many of these providers lack any formal training in chronic pain medicine and sometimes also lack appropriate physician supervision. Such poorly supervised midlevel chronic pain prescribing can lead to disastrous results.
A new form of distressed chronic pain physicians has only begun to surface. This group is made up of physicians who perform invasive office-based procedures and whose only interventional training has been short CME courses on such procedures as nerve blocks. PowerPoint slide shows and brief cadaver labs do not an interventionist make.
In many situations, practice remediation can be successful. During evaluation and practice remediation every effort is made to preserve the dignity and confidentiality of the doctor/patient relationship and to avoid embarrassment or negativity. Such practices need some degree of ongoing practice monitoring in order to prevent practitioner back-sliding into unsafe practices. With well-crafted board orders and written releases, the status of a physician’s post-remediation compliance can be regularly communicated to regulatory boards, hospitals, attorneys, partners, medical insurance companies, liability carriers and other governmental entities. Please see my article “Guidelines for Medical Board Investigators and Consultants Dealing with Distressed Pain Medicine Practices,” published in the Volume 91, Number 2, issue of the Journal, for more details on evaluation and remediation.
CONCLUSION
The present situation is clear: Either physicians and other stakeholders need to seriously deal with prescription drug abuse and diversion, or the government will do it. The medical profession must better train and police itself in order to avoid being forced to take many giant steps backward into a setting where chronic pain patients were undertreated, ignored, shamed or labeled as hypochondriacs and malingerers. The time to act has come.
