Let’s look at the case of Vicky.
In pain off and on for many years due to a motor vehicle crash, back pain, neck pain, and a brain injury, Vicky came to me having been dropped by her “pain doctor”. She had been on Suboxone for a couple of years getting very little “pain” relief.
I figured I’m just there to help her through the withdrawals. I was pretty sure she was dependent. From what I’ve heard withdrawing from Suboxone is challenging at best. We did a fairly rapid wean, Got her down to hydrocodone and tramadol.
MMJ was prescribed but she did not follow up on that. Then her pain began to increase in her hands wrists elbows and knees-all new areas.
She responded quite well to a burst of prednisone. She didn’t have insurance so she declined to work up until she could get Medicaid. Lab work then revealed that indeed she had an elevated sedimentation rate and her rheumatoid factor was off the charts, and this was a new finding.
There are two local rheumatologists one with a long waiting list the other was a short one. The doctor with the short waiting list was picked first and after a couple weeks it was revealed that he does not take Medicaid! The other more established rheumatologists has a three month wait.
By this time the patient is in agony with her pain and I prescribed a stronger narcotic for her.
Here is where it gets interesting (if it hasn’t already)
I received a letter from the drug utilization review committee for Montana Medicaid which stated: “the committee has met and feels that it is inappropriate to treat rheumatoid arthritis with opiates. This could mask progression of the disease. The patient should be treated with an immune modulating agent reserving opiates for later in case immune agents don’t work.”
This is great logic given that she could get into a rheumatologist but based on her insurance and delays I called up and asked what I should do in the meantime. I was told: “you’re going to have to wait of course, until she sees her rheumatologist”.
I informed the representative of the DUR that there was at least a six week wait until she could see an out-of-town rheumatologist in March, assuming she could get a ride there.
I asked the pharmacist representing the committee why on earth we wouldn’t treat someone’s severe pain while they were attempting to get it treated, and she did refer back to the previous Suboxone medications as some unwritten rule indicates that she’s not to be on opiates.
In my humble opinion this is tantamount to refusing morphine for appendicitis until it is treated or awaiting pain relief while a kidney stone passes because it may not ultimately be needed.
I do not comprehend the heartlessness of a committee that would recommend someone with a new diagnosis of a painful condition not receive pain relief while their condition is being stabilized. These people would never ever get away with managing someone in pain that way unless they were on Medicaid.
The premise that opiates not being used for humanitarian relief while her diagnosis is stabilized or even established is indefensible at best and preposterous and inhumane at worst.
Who are these people, and who put them in control?
Who wrote these new rules? –The ones that say that pain can be ignored that people can be left to suffer at the whim of some committee members who remain anonymous?
I offered to refer the patient to any of the number of members of the so-called drug utilization review committee, but that idea was ill -received. (Actually: they declined).
Vicky and patients like her must actively begin to stand up for themselves vigorously and have permission to do so. My advocacy can only go so far, I’m not the customer of the drug utilization review committee. They don’t really care what I think, they will only respond to political pressure. The current political pressure says–and I’m paraphrasing here–prohibit opiates, particularly to poor people who have very few other resources.
The 100 million patients in pain in the United States could form a very strong voting bloc if they began to speak for themselves, advocate for themselves, hire attorneys, and bring the class-action lawsuits that are required to shift this discourse to another direction. Or generate a modern day Manhattan Project, as I read recently in the National Pain Report.
I’m reminded of my service in India: in 1989 in Calcutta what was needed was not another doctor. What was needed was a civil engineer, Sewers, reliable electricity, ventilation, pollution controls. Plus viable wages, nutrition, public health nurses.
Today’s pain patient needs a competent physician to listen and co create a viable diagnosis and plan.
A great lawyer, political operative and media person might be just as important.
Editor’s note: Mark Ibsen, MD, is the owner of an Urgent Care Plus clinic in Helena, Montana. In a previous column, Dr. Ibsen wrote about the many pain patients he was seeing who were unable to find doctors willing to treat them.
Dr. Ibsen 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.
The information in this column is not intended to be considered as professional medical advice, diagnosis or treatment. Only your doctor can do that! It is for informational purposes only and represents the author’s personal experiences and opinions alone. It does not inherently or expressly reflect the views, opinions and/or positions of National Pain Report or Microcast Media.