On an unusually warm but rainy December day in Little Rock Arkansas, the Arkansas Medical Boards’ Pain Committee held their final meeting of the year.
Sitting in the back of the Arkansas Medical Board’s conference room, where the meeting was held, a group of advocates from Arkansas and Oklahoma waited patiently hoping to be heard. That chance never came, but the meeting was an eye opening experience and what was heard served as a valuable learning experience and will set the stage for future advocacy techniques that can be applied in the future.
An overly simplistic description of what happened can be found in what I refer to as the new mantra of opioid prescribing in America.
In todays over-reaching and restrictive regulatory prescribing environment a decision must be made to continue treating the patients who DO fit within the guidelines; leading to medical professionals being forced to weed out and refer out ‘those few’ who are too sick or suffering too much to be treated inside the guidelines.
This new attitude is likely putting the patients with the most complex cases, the weakest, and the sickest in our society in a position of ineffective, reduced, or non-existent appropriate care.
Setting the Scene…
Inside was similar to a court room; the ‘Pain Committee” and a few others sat on a raised platform across the front of the large room. In the enter of this room was a table equipped with a tall, thin microphone and an office chair; that’s it. The public seating was located behind the ‘witness’ table in the center. The pain committee appeared to be made up of 6 members, all physicians in Arkansas. On the far side of the raised platform sat an attorney for the Medical Board and two lovely younger ladies; one appeared to possibly be a transcriptionist recording an account of this meeting and one who never spoke but appeared to be taking notes.
It is important that the scene is engrained in your mind in order to fully appreciate the stage that is set in these meetings. We sat (in chairs obviously not made for those of us with painful spinal conditions) quietly as all of this unfolded. This committee meeting consisted of publicly reviewing three physicians’ prescribing habits. More than once a committee member reminded a physician that they were not a disciplinary board, and it seemed as if the members truly cared about keeping these practitioners working and on the right side of the medical board. They had each of the three physicians come in one at a time and sit at the small table in the center. The board would tactfully go over any concerns while complimenting them whenever possible.
And so it begins…
The first time I heard this phrase, it shook me to the core:
“Decide which is more important; the majority of patients or ‘those few’ who will not allow you to run your practice the way you should be running it”
It turned out, we would hear something similar to this many more times, reminding each of the 3 physicians the only way to stay in practice to treat the largest part of their patients was to either refer out or radically change the treatment plan for ‘those few’ patients that did not fit inside the small box that is now opioid prescribing within the guidelines/regulations/recommendations/laws. Each of the 3 protested to varying degrees about being forced to all but disregard patient outcomes in order to comply with Regulation 2. The first one was very gentle with his dissent, he seemed the most rattled by the process yet the committee had the fewest criticisms towards his prescribing habits. The second on was more firm and specific with his objections, but had already decided to quit providing pain management to his patients, although the committee assured him that if he would get his patients under the magic numbers provided in the guidelines that he could continue to provide pain management to his patients, as he specialized in rheumatology and many of his patients have a justified need for pain medicine. The third physician was a silver haired man who was the sole survivor of what once was a bustling ‘old-fashioned’ practice with 7 providers. He was working towards retirement, and had the most stern criticism from the committee. He spoke very firmly about needing to continue to help his patients, even the ones that fell outside the guidelines. More than once, the words he said to show his disapproval of having to choose between the majority and the most vulnerable patients was priceless. My favorite was:
“These (medications) are a gift from God to get some relief. I can do more to limit these drugs but that… (silent pause followed by a distressing sigh) it’s hard…(inaudible mumbling)…”
While the committee all overwhelmingly agreed that no one wants to see patients suffer, they reminded him that 75% of his practice were not pain management patients and counted on him to remain in practice. Unlike the first two physicians before him, the committee gave the aging practitioner a set of very strict ‘rules’ that he must follow in order to keep his license. The medical board attorney spoke up and emphasized that he had been in trouble with the board, as well as the DEA, before and they would expect him to follow these ‘recommendations’ to the letter in order to remain in practice. Once again it was reiterated:
‘(You can) still take care of them but not (prescribe) more than the cdc guidelines allow. (It) Takes the risk out of your practice significantly’
With the completion of the third prescribers review, the committee announced they would take a break. Those of us waiting to be heard were then informed that, although two of us had called to confirm that we would have our chance to speak, we had not followed the required procedure to be allowed a comment period. We quickly exited the building filled with disappointment and other mixed emotions.
My personal thoughts…
Considering these were all highly respected professionals in the medical community, I was surprised to hear some of the comments that came from committee members. I took offense when the words ‘those few’ and ‘cripples’ were used to refer to patients like myself who did not respond the way they expect to the doses allowed by Regulation 2 or the CDC Guidelines; and I cringed when one said that patients who were hard to taper might be addicted; but I almost came out of my seat when the head of the committee said that 5 million people had died (or will die) of overdoses in a 15 year time span. Hearing such an obviously fabricated statistic used to show the urgency of tapering to guidelines sent me into a frenzy looking for accurate information so I could correct him during the public comment period (that I still thought would happen by this point), and found this number was inflated by 25 times the actual figure. The HHS website says:
“From 1999 to 2016, more than 200,000 people died in the United States from overdose related to opioids”
That is a far cry from the 5 million he undoubtedly heard in the media. Even multiplying the number of overdoses from ALL drugs at the peak of this overdose crisis (72,000) by 15 years to attempt to predict what could happen only totals just over 1 million. There is no reason other than instilling fear and spreading misinformation for such an egregious lie to be repeated.
The common theme when referring to ‘getting (or doing) it right’ was in reference to tapering and reducing prescribing, with concern for patient outcomes being rarely mentioned. (This is likely due more to the intent of this meeting to review prescribing habits and hopefully these issues are considered separate agenda items). Most of the committee members agreed that ‘Regulation 2’ as well as the CDC Guidelines were not ideal, using words such as ‘random’, ‘political’, interference’, ‘problematic’, and others. While they all seemed to dislike the new restrictions, at least one of the members (a general anesthesiologist) was adamant that 50–90mme was more than appropriate for patients. That deeply concerned me considering as an anesthesiologist he would never give a 400lb man without kidney or heart issues the same dose of ‘sleepy medicine’ as he would give a 105lb woman with kidney and heart trouble. That would be a recipe for disaster for both patients, and it seems that this alone would remind him each patient is unique in their need for pain control and the doses/medications that are effective.
While I was pleased to learn that Arkansas had a ‘middle man’ committee to help correct issues identified before the medical board took further action, I left physically sick to my stomach knowing these hand-picked and highly respected pain management physicians (and other related specialists) seemingly went along with the creation/enforcing of Regulation 2 instead of using their influence to speak out for patients and their physicians who do still treat pain where ALL patients function and outcome is seen as first priority. The feeling of disappointment in these committee members, as well as many other medical professionals who have quietly sat by knowing the damage that was being done to their patients as well as to the sacred doctor/patient relationship is only slightly diminished by the knowledge that standing up for the most vulnerable has cost many physicians their license, their livelihood, and likely most of what they spent years working to save/create for retirement. It now seems that until the ‘groupthink’ mentality begins to lose favor and Americans begin to think for themselves again using logic and common sense, instead of believe in whatever the media and government has decided is the most convenient narrative, millions of patients will continue to suffer in order to appease a few policy makers who have been proven to be benefiting from these new guidelines ad definitions. This is a sad fact of American life that will likely continue to get worse until a more profitable endeavor emerges and entices policy to return to compassion towards the most vulnerable.