(Editor’s note: Mark Ibsen, MD, is the owner of an Urgent Care Plus clinic in Helena, Montana. He is currently being prosecuted by the Montana Board of Medical Examiners for over-prescribing narcotic pain medications and keeping substandard medical records. A decision by the board on whether to revoke his medical license is expected soon.)
I was at lunch, just sitting there talking to my friend, Mike. We were chatting about how our holidays went, and mine had some ups and downs. I’ve been obsessed with getting through my trip down the rabbit hole with the Montana Board of Medical Examiners.
Mike teared up. “The thing I love about you Mark is that you’ll see anybody, won’t you?” he said.
My eyes got wide and I replied, “Of course, what else would I do?”
Mike was referring to the 22 “narcotic refugees” that I began seeing last April. Their doctor’s office had been closed in a DEA raid and the doctor’s license was suspended indefinitely by the state board. In the intervening eight months, no charges have been filed against the doctor, but his patients have had to fend for themselves, obtaining treatment for their chronic pain issues.
Many came to see me in Helena. It is often said that Montana is one small town with very long streets. Going a couple hundred miles to see another physician is not that big a stretch for me, but it is considered a red flag for possible drug seeking or diversion according to pharmacists in my area.
So when my friend Mike got teary eyed about my service to these so-called narcotic refugees, I found myself a little perplexed. Of course I would see whoever comes through my door, particularly if they’re suffering. I don’t care if they’re having acute pain or chronic pain, if they’re in withdrawal, or if they have been abandoned due to actions by their doctor, pharmacist, or a state or federal agency. It doesn’t matter to me.
This situation called for a response along the lines of the Good Samaritan. I wouldn’t drive by a car wreck with an unconscious fellow citizen lying on the ground. And I certainly wouldn’t fail to respond to a call for help from the cockpit on an airplane flight.
I am wired to respond with my skill set when a contribution is needed. Of course I was shocked and chagrined when I heard that the unintended consequences of an action against a fellow physician was the closure of his office, confiscation of his records, and abandonment of all his patients. I know that if I did that in the course of my daily medical practice I would lose my license. And rightfully so.
So my automatic response in seeing the first patient on April 14 was to “spring into action.”
I wasn’t necessarily thinking about the consequences to me or my license. I was thinking mostly about the consequences to the patient for being in withdrawal and acute pain. I was concerned about the betrayal this patient was suffering from. He couldn’t find his doctor and his doctor’s office had crime scene tape put up across the door. He didn’t know what to do.
Articles in the paper mentioned patients doing a “rapid wean” with the medications they had left, but no word about where any of these patients could go to find alternative care after having their primary caregiver taken from them.
Now I find myself under investigation by the Montana Board of Medical Examiners. The attorney for the board has requested that the DEA investigate me. Two agents came to my office to interrogate me about my practice. While I found this somewhat terrifying, I thought the answers I gave were appropriate and responsible. I told them in no uncertain terms that I don’t run a pain clinic. I operate an urgent care clinic.
I also told them that I’m also concerned about red flags. I even notified them that several groups of related people were coming to see me from that previous practice. This looked initially like a potential “family business.”
I assumed that informing the agencies about this would satisfy my obligation to make them aware that there might be some people who could be breaking the law. Of course it’s also plausible to me that each of these patients had a good reason to be on their high dose opiates. I considered it to be a secondary issue however, since I had access to a prescription drug database and could see that each of these patients had been on very high doses of opioids for a long period of time, obtaining them consistently from one provider.
Of course, their doctor’s records were unavailable as they had been confiscated. But I did not feel I needed medical records in order to treat a person who is in pain and withdrawal. I consider them to be in a metabolic and physiologic emergency. Just like I would treat anyone who was dehydrated or having a heart attack – I would not care about their previous records during the initial phase of evaluation.
After eight months, most of these patients have moved on. Several I tried to refer to pain clinics out of town, to no avail. There is no actual ongoing chronic pain clinic operating in my town.
Those out of town pain clinics require pill counts to be done randomly, and the patient must live within an hour of the medical center in order to do the pill count. Therefore they won’t take any referrals of pain patients who live outside the area.
They also won’t take any patient of the doctor whose office was closed. He is now a pariah. All of his patients are being discriminated against. No other physician is willing to see these patients. They are truly “narcotic refugees.”
Yes, this appalling behavior is occurring right here in America, the land of the free and home of the brave.
Oh, and the doctor whose office was closed? No charges have been filed against him so far. Meanwhile, I’m scrambling to save my license because I’ve been accused of over prescribing narcotics to these patients as I have weaned them off high doses.
During these last eight months I’ve learned a lot about chronic pain, high dose opiate use, and the aphorism “no good deed goes unpunished.”
While it seems like an obvious assumption that family members moving in a group to obtain opiates would likely be diverting drugs, that didn’t seem to fit this scenario. I ultimately found a DNA test for opiate sensitivity. The family members that I have tested have uniformly turned up positive for “rapid metabolizer” status, indicating a need for high dose opiates to relieve any pain at all.
Naturally, and somewhat obvious at this point, genetic abnormalities run in families!
While two of these 22 patients did alter prescriptions and are no longer obtaining prescriptions from me, it is not clear whether those alterations were done in order to divert drugs or a manifestation of pseudo-addictive behavior.
There has been a change. It’s a radical change. Our patients are no longer our patients. The patient-physician relationship is in jeopardy. Right now, fear is the operative modality.
I am finding more and more that pain truly is a freaking terrorist. And terrorism has people sometimes behaving at their best, and sometimes behaving at their worst.
We actually get to choose, don’t we?