The Chaos of Pain Medicine in 2015

The Chaos of Pain Medicine in 2015

Richard L. Stieg, MD, MHS

Richard L. Stieg, MD, MHS

Dr. Richard Stieg of Denver, Colorado is 78-years old. He’s a former president of the American Academy of Pain Medicine. He has seen a lot of things in pain management.

But nothing he has seen is quite like what he sees now.

“This is the most chaotic time I’ve ever seen,” he said. “I’m glad I’m nearing retirement.”

Dr. Stieg spoke at the Southern Pain Society meeting in Orlando, Florida this week where his message was about how medical providers need to identity and define risk strategies for themselves and their patients if they choose, or as he said “have the courage” to treat some of their patients with opioids.

The risks are plentiful:

The scrutiny of the regulatory agencies in local, state and federal governments, plus what Dr. Stieg terms as guidelines imposed mostly by non-medical bureaucrats in managed care companies and other third parties provide what he said is a “double edged sword” for both patients and providers.

Dr. Stieg remembers a simpler time.

When a pain patient was looking for help 30-to-35 years ago, there were alternatives like programs that emphasized physical restoration, biofeedback as well as psychological and dietary counseling.

Those programs were then largely covered by a patient’s insurance.

Since managed care began, and, as he said, “started ratcheting down coverage for chronic pain, mental health and other chronic illness,” these programs are largely not insured today. Most patients can’t afford to pay for them out of pocket, so many who could benefit, aren’t able to.

“Without having those options, we found ourselves prescribing strong pain medication more frequently because we had fewer alternatives to try and also found that pharmaceutical companies started to develop more opioids and dominated our medical meetings with information about them.”

The pendulum had swung all the way from never using opioids in the late 1970s to using them almost indiscriminately.

Now, because the DEA and state officials have begun to crack down, the pendulum is swinging back, and Dr. Stieg feels like it might be swinging back too far and too fast.

He told the story of a recent visit by a patient who had been denied a prescription by her health plan–a prescription that she had been using for two years.  She told the doctor she was informed by her health care plans that she now needed a prior authorization before they would fill it.

Dr. Stieg reminded her that every patient in his practice (including her) had received a letter from him two years ago saying his practice, a small practice, didn’t have the time or the resources to do that. anymore.

To punctuate that, he had her stay in the office (she was his last patient of the day) and listen to what he had to go through.

“I called the health plan and after waiting on hold for a while I spoke with a person. I asked if he had a medical or pharmacy background and he said no,” Dr. Stieg recounted.

I explained to him who I was and my background and the unique reasons that the woman was receiving the medication that she had been prescribed for the past years.

” He said, you really need to talk with a pharmacist.”

Dr. Stieg asked to be transferred to one. This may sound familiar to any of you who have tried to get answer from your health plan.

After minutes more of being on hold, the customer service rep came back on and told Dr. Stieg that the pharmacist said it was denied.

Dr. Stieg pressed, saying he wanted to talk personally to the pharmacist who he did (after another short delay), explained everything to the pharmacist who ultimately said that both he (Dr. Stieg) and the patient would have to submit written appeals.

It took 25 minutes and the answer was no.

The patient was amazed and obviously upset.

For Dr. Stieg, that story, which he planned to tell the audience in Orlando is emblematic of the problem in health care too—too many bureaucrats in government, health care plans and pharmacies and not enough common sense.

Dr. Stieg, who will retire in the next year or so, has embarked on a program in his practice to taper about 100 of his patients who use opioids. (We reported on it recently–click here).

He’s doing it because he doesn’t believe those patients will be able to find doctors who are less inclined to accept new patients who are taking opioids because of the regulatory scrutiny.

“Doctors are frustrated, patients are frustrated and they both should be,” he said. “We can do better.”

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Authored by: Ed Coghlan

There are 5 comments for this article
  1. Susan in Texas at 3:11 am

    I am a 10-day post surgery patient with a total knee replacement. I’ve been taking Percocet 5-325, 2tab each 6 hrs and experiencing break-through pain. My Dr gave me 30 tablets on refill which is only 3 and1/2 days of medication. EACH refill requires a new script with fresh signature that must be picked up from the Dr office during business hours and carries to the pharmacy. I AM household. This requires me to find a person who can get the script & deliver it to pharmacy since electronic filing isn’t allow under new rules. On Friday, awaiting word on another refill, I received no confirmation to pick up the prescription despite my calls to office. Dr office closes with my script on the desk. I AM out if medicine and screaming.
    No way to get help. I just have to wait til Monday. By luck, I got Percocet leftovers from my neighbor who just finished a knee replacement. That saved me from excruciating pain.
    Now, why are there no step-father procedures for someone who can’t get the signed script on time. The next morning I received call from Dr. saying HE DID leave a signed script, but the office closed. No compassion or presentation if an alternate method if getting the signed script. Does this mean legitimate users of restricted drugs suffer, go to an ER OR WHAT……
    THIS “LAW” was not thought out well. Doctors have not provided adequate means in dealing with it. Obviously the rules/procedures were designed by someone who has never been in serious medical need of the drug, and never had to deal with the actual difficulties of getting the drug when one cannot drive, and Dr offices do not allow patients to speak to humans, only computerized answering systems that are not in fallible. (How about a menu option for “post surgical patients”. I’m very angry depressed, and disheartened.

  2. EDSsufferer at 7:47 pm

    Stephen, we needed the ACA at this point to update insurance companies. With all the new diseases and medications out there, something had to be done. I don’t think insurance companies have updated anything since 1960, but don’t quote me on that. Insurance companies had 3 years to prepare for the ACA and they didn’t do it! They didn’t want to be told what to do and they still don’t. And you can’t blame the ACA for insurance premium increases because they are NOT regulated and can do whatever the heck they want to do and charge for someone’s premium! So the ACA was a good start. It’s not perfect. I would much prefer Universal Health Care but a lot of people want single-payer. Single-payer would make the insurance companies soooooo happy because they wouldn’t give a crap what they charged for premiums! Insurance companies needed to be updated. Yes, it is too bad that people’s insurance companies fooled them and left them without health coverage. Again, not the ACA’s fault!

  3. Stephen S. Rodrigues, MD at 7:01 pm

    I have to confess that I was a little excited that one of my daily irritants, before the ACA, was that my patients could not afford insurance or they were denied because of prior illnesses. Well time has exposed the devil deep within the details of the ACA!

    After 18 years in solo practice, it is now a living hell! My view is that the ACA will accelerate the demise of modern medicine as we know it today. [hopefully without a war]. There is way more paperwork, prior auths, phone calls and rejections.

    Before there was a small amount of formal trust and a little leeway amidst the insanity. I could help my patients out of pain with the use of a few CAMs-like treatments. 6 months ago I could get the ends to meet even when many were not paid but they helped my patients. NOT anymore! Now it is full blown insane, so I can no longer afford to help my patients out of pain.

    Somewhere embedded in the pages of the ACA are barriers to keep patients STUCK in the conventional medicine:
    They do not trust primary care doctors who are not fully in the box or free thinking.
    They do not trust their beneficiaries who cry out in pain.
    They can keep a patient from restorative care by calling them to let them know that the “free acupuncture” and the injections are barred which no exceptions.
    They are told that before they can get a few simple trigger point injections targeted at the pain site, they must have failed a “corrective pain surgery.” One of my patient’s had 10 failed surgeries; 2 knees, 2 back, 1 shoulder and 4 hips and they said NO to further injections.

    Now they also have these for-profiteer auditors who can request an old chart and if they feel like the patient was not in enough pain, they order you to repay the bill. The auditors get a cut of the repay. All of this is blinded without a patient interview of what actually happened.

  4. EDSsufferer at 4:44 pm

    Dr. Steig is absolutely correct! Most Plan D companies have changed their formularies and have made it harder to get the meds that we used to take last year.
    I use a lot of Lidoderm patches and they were covered last year but not this year. They are $750 per box of 30. I think it’s quite ridiculous. So I had my Pain Dr give them a prior auth and after nothing happened for like a week, I called Silver Script and told them I wanted to talk to the Pharmacist because the customer service people have no clue what these meds are and you won’t get anywhere with them. So I have always had to advocate for myself to get what I need. Dr’s are afraid to give people narcotics because of the strong crackdown and that is not fair to those of us who suffer daily with chronic pain. Mine comes from a genetic disease and so I rely on my meds. A lot of patients Dr’s won’t fill their scripts any longer and so they have to suffer through withdrawals, which is so dangerous to go through.
    The FDA and CDC and all these other organizations aren’t recognizing the difference between addiction and dependence. Addicts want the high. Someone who is dependent, I don’t look for the high, I want pain relief. Other alternatives that are recommended by the FDA and CDC do not work on me and actually causes me more pain. It’s really sad because I know a lot of chronic pain patients that are having to turn to the streets to purchase any kind of pain med. We aren’t going to turn to heroin etc. Just give me my morphine and butrans patch and I’m fine unless my pain goes over my normal 5-6 and then I try everything I have for the pain. If all fails, I will smoke some weed and my pain goes away within minutes! Not legal here but it’s all I have to turn too when all else fails. It’s really sad to see my piers turning to the streets to stay pain free. But that’s what the FDA and CDC are making us do!

  5. LouisVA at 3:03 pm

    Dr. Stieg said, “The scrutiny of the regulatory agencies in local, state and federal governments, plus what Dr. Stieg terms as guidelines imposed mostly by non-medical bureaucrats in managed care companies and other third parties provide what he said is a “double edged sword” for both patients and providers.”

    I could not agree more. These regulatory agencies produce guidelines that many officials and courts seem to interpret as LAW. My insurance company cut their payment on 50% of my pain meds. Do they have a medical license? Of course not, but I thought they were required to pay for what my doctor prescribes. They told me that “I am obviously in severe pain and the treatment is WORKING but it does not comply with standard medical practice” so I am now paying over $5000 per month out of pocket. I have a CYP2DC genetic defect that causes me to be a poor metabolizer but that does not matter to them. What matters is the almighty dollar not my health.