Treating Chronic Pain Patients—Getting More Scrutiny

Treating Chronic Pain Patients—Getting More Scrutiny

mark ibsenLet’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.
Just sayin’

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.

 

Authored by: Mark Ibsen M.D.

newest oldest
Notify of
Sandy

Dr Ibsen,

Regarding the statement “previous Suboxone medications as some unwritten rule indicates that she’s not to be on opiates.”

At this point in time the FDA has not allowed the use of buprenorphine to be used as a chronic pain medication. It is in the EU, UK, Canada and Australia. It is I believe being considered. The only application the FDA currently allows is for opiate abuse.

I was doing research on medications my Medicare Advantage plan covers. Was aware of buprenorphine as a chronic pain medication and asked my doctor about it. What I was told by both doctor and his staff was very clear. 1) they didn’t think it would be strong enough for my needs and 2) once put on it, the label would follow me *forever* [or until it is accepted by the FDA for use in chronic pain] and would be unable to go ‘backwards’ to my previous medication if it didn’t work.

[sorry for possible duplicate comment. It seems the system ate my previous one. thanks! Sandy A. Sullivan]

BL

The politicians are the ones that control things like this. We are at their mercy. The majority of the general public sees Medicaid patients as lazy, not wanting work and often drug addicts if they are on certain meds, thanks to the media and the politicians. Ameritox put out a report several yrs ago that stated those who received Medicaid were more likely to use illegal drugs which supports this picture.

“In 2010, I sent a letter to all 50 state Medicaid directors asking them for their top ten prescribers of the top eight most over-prescribed drugs on the market. Many states provided the data I requested, and the statistics were alarming.”

Grassley Pursues Prescription Drug Abuse in Medicaid, Medicare-
http://www.grassley.senate.gov/news/news-releases/grassley-pursues-prescription-drug-abuse-medicaid-medicare

Medicaid Patients More Likely To Use Illegal Drugs-
http://nationalpainreport.com/medicaid-patients-more-likely-to-use-illegal-drugs-8815665.html

Kathy Hastings

I think this man is a doctor who should be a role model for all doctors! He truly cares about his patients and their individual plights! I have watched several videos with him discussing pain in open forum with his patients. The only other doctor I have ever experienced doing such was a chiropractor. I am appalled he is being harassed and can possibly have his license suspended for treating a patient as one, an individual and two, with compassion!

Donna- FFPCAN

Wow Dr. Ibsen. That is horrible! Outrageous more like it!
The climate so the DEA call it now, is very chilling and at the very least, INHUMANE!! You did try your very best and I’m sure Vicky was pleased and very appreciative about your efforts.
WE all know there about 100 million or more, who suffer with chronic pain, the questions is?? How do we get them to know that there are people and organizations out there to let me know they are not Alone? That we are trying to fight this monster, called idiot prescription pill epidemic. It’s So BOGUS for sure!?

Many chronic pain patients may not even have internet and this the main way that we are all trying to reach out to them and many have no idea… I had mentioned about getting a huge billboard sign near the local Hwy’s, maybe all of us orgs and advocates? Should create an event together to raise money to lease several of these and maybe even grow more to get our advocacy efforts out across the country?
WE need as many of these unknowing people who suffer pain and their caregivers that we can possibly get to help us FIGHT!!

All these poor patients are being turned down access to get pain relief at so many angles here.

WE need to change to tide back to days when the American Pain Foundation was around and lobby if that’s what we need to do, to get suffering humans the relief they deserve. Too bad for senators who didn’t approve of APF. They were very wrong by attacking this org. They were helping this fight for access.

The US Gov, DEA, medical boards in certain states, Governors, Attorney Generals and the boards of pharmacy have got to change their ways!

Ok.. so the pill mills have been taken out and they are gone.. But were all these pain orgs were advocating for the legitimate anyway!

I hope that we can all work together and start looking for new ways to get patients involved in Fighting For Their Rights! Definitely #givepainavoice is awesome! I also hope that many will find my group too, Fight For Pain Care Action Network. With just a little more support, we can get more awareness out to those who need us!

Thank you Dr. Mark Ibsen for all the advocacy your doing! We definitely need more Doctors on the patients side and WILLING to speak to out to like YOU, sadly.. not enough are helping.. Thank you once again, for all you do.
Donna

Amber Bergstein

Great article. Thank you Dr. Ibson for fighting for your patients, even when you’re under attack yourself. You’re a hero to us chronic pain sufferers. Wouldn’t it be great if we all had the RIGHT insurance, enough money for all the bullshit testing we are put through, and all the expensive drugs they put us on THAT DON’T WORK. They want to give everyone cymbalta, but no one tells you that comes with a $750 price tag, and many insurances won’t approve it. Or that Zanaflex (non-controlled muscle relaxer) is $375. People with insurance get denied the meds, and people without cannot afford them. Plus….they don’t work for probably 75% of us, or only a bit. I have suffered with chronic pain since 1997. I was 22 then. I’m 40 now, and I’m exhausted. I tried EVERY medication they threw at me. Narcotic or non-narcotic. When I was 30 I was on 20 medications, only one was a controlled substance at the time. I decided enough was enough when I started hallucinating pink and green frogs everywhere, and I hadn’t taken ANYTHING controlled that day. It was from a combo of gabapentin, amitriptyline, wellbutrin, zanaflex, hydroxazine, singular, trazadone and all the other crap I was filled with. I decided to get rid of the meds and do as much alternative as I could. When I went off of those drugs I felt HUMAN again. I was put on a long acting narcotic and a breakthrough pain med, and I did the rest with alternative. It made me 100 times better. I have never asked for scripts early, sold my meds (no chronic pain person sells their meds. . Duh) or have done anything else to be considered a seeking patient. I’m tired of hearing I don’t “look sick” and being denied the care I deserve. To top it all off, I’m in the medical field and married to a surgeon, but that doesn’t seem to make a difference either. At this point life is no longer very worth living. Pain takes everything from us, yet the ONE THING that can give us just a tad bit of relief, is denied. It doesn’t KILL the pain by any means, it just makes it more tolerable. I’m sorry for all the addiction problems, but in my area heroin is what’s big, not pills. Pills are expensive, so addicts want a cheap high. I can’t help what other people do, but I’m DONE being punished for others bad behavior. I’m angry, I’m humilated and I’ve lost all faith in medicine, and that means I’ve lost faith in my own career choice. I used to think going to the dentist was the worst thing. Now….it’s going to ANY medical doctor. It sets a level of anxiety that I can’t even explain. So, I want to again THANK YOU for being one of the few doctors willing to SPEAK UP and stand up for those of us who need it. I hope and pray that… Read more »

Jay Fleming

Dr Ibsen I’m a former Montana undercover narcotics investigator, and curent chronic pain patient for the last 20+ years. I saw what happened to my first real pain doc in 1996, Dr William Hurwitz.

I’ve been a speaker on drug policy for a law enforcement group for over 10 years. I reviewed cases for other physicians with problems with the medical board. If I can testify, or help in any way, please let me know.

Jay Fleming
leapspeaker@gmail.com

Coonhound

Where to start. First off let me thank you again, Dr Ibsen.1,000 times would not be enough, for having the morals, conviction, and BALLS to do what is right while being threatened w/ your livelihood. If even half of the doctors in this country would do the same the DEA would be screwed, they can’t put half the doctors in this country in prison. BUT,they sure can whip them into line along w/ these Medical Boards though picking ’em off one at a time. A good start one would think would be for whistle-blowers at DEA to come forth. Well they’ve been there and done that for YEARS. Google ‘Deep Cover’ by Michael Levine. They have come forth and are routinely marginalized if acknowledged at all. See Levine (DEA) Bonner (Head of DEA and a judge on 60 minutes w/ Mike Wallace for Chrisake) exposing CIA and DEA involvement in drug trafficking. https://www.youtube.com/watch?v=pFySU7FUzhk Of course it could be worse, see the case of poor Gary Webb who died of suicide (TWO gunshot wounds mind you…..hmmmmm). after exposing CIA and implicating Reagan Administration higher ups in cocaine trafficking in IRAN CONTRA scandals. Old news you say? Fast and Furious is pretty recent just ask longtime ATF agent Cefalu (widely acknowledged as a excellent agent in reviews and assignments) who was summarily dispatched after 20+ yrs of service. All he got for his troubles was 85 grand and a dont let the door hit your a** on the way out. http://townhall.com/tipsheet/katiepavlich/2014/10/07/after-inappropriate-firing-atf-settle-lawsuit-with-agent-vince-cefalu-n1901826 Disabled patients are being painted into a corner where actions they make in which they have no choice are counted as red flags against them. Use too many pharmacies (pharmacy shopper) never mind that it takes 3-4 pharmacies *if lucky, to fill your Rx throughout a year. New Medicare Guidelines point to YOU as an overuser and most likely abuser and likely to be ‘assigned’ or ‘locked in’ to using one doctor/one pharmacy in which to get all your controls written and dispensed. Think it is hard gaining some quality of life now? We haven’t seen anything yet. Coming soon to a hospital/doctor’s office near you. http://www.hematology.org/Advocacy/Policy-News/2014/3300.aspx On a personal note. It isn’t just controlled meds. I fought Medicare/Express Scripts/BC/BS for almost 2 weeks to gain access to nebulizer meds (one ‘reason’ given in a COURTESY CALL from Express Scripts was that they couldn’t verify that I had the equipment to use the medication-a nebulizer, are you kidding me?) Lets keep in mind that I have asthma, Interstitial Lung Disease(sarcoidosis), and chronic bronchitis and was just recently released from the ER and seen by my pulmonolgist AT LEAST A DOZEN TIMES SINCE JULY. Oh yeah, I almost died from total respiratory arrest in 2ooo on way to the ER. During this time fighting for breathing medication I was coughing so violently that I thought I pulled a muscle in my back. Wouldn’t suprise me, I had given myself a hernia last year hacking. I thought I pulled a muscle in my… Read more »

Kurt W.G. Matthies

Last year, over 2,000 physicians were investigated by state medical boards and federal oversight agencies. Many have lost their license to prescribe controlled substances, and some are today serving prison terms for treating people with intractable pain. This scrutiny is occurring all over the country. As a result, people in pain who once received adequate and effective medical treatment now suffer needlessly.

Is there a sound medical basis for this scrutiny? In Dr. Ibsen’s case, the overseers don’t seem to care.

We are a huge block of voters — why don’t we use this power to kill this “war on prescribers” and create a more compassionate medical community?

Kacyjaye

Dr Ibsen,
As a person who has chronic pain stemming from several conditions including: Lupus, Interstitial Cystitis, Pudendal Neuralgia, PFD, and several other causes; and as a person who is very fortunate to also have an outstanding Dr who also advocates for proper pain management, I just want to say thank you.
Thank you for being a Dr who seems to put his patients best interests ahead of the “status quo”. Thank you for standing firm in your beliefs, and staying true to the oath you and all physicians take that includes, “…First do no harm…”.
Because chronic pain IS harmful. And the way some of my fellow peers who have chronic pain are treated, or rather under treated or even not treated is not only very sad to me, it seems criminal, and harmful.

I hate to wish anything negative on another person; but I do think if some of the so called “rule makers” had to try and live with chronic pain for even one day, without the medications that have been proven to help many of us enjoy an improved quality of life, they’d be advocating just as you are. And they’d be doing it fast…

I understand there is a problem with abuse of pain medication. What I don’t understand is criminalizing and even punishing the medical personnel who are trying to legitimately assist those with chronic pain, and the same punishment being done to those of us with legitimate pain…by making it difficult to impossible to obtain our medications.

People who abuse the medicines are still going to find a way to obtain and abuse them, they always have. It’s those of us who have always tried to follow the “rules” who are and will be punished.

I see what you are going through, and I literally pray that my physician, as well as the other professional, compassionate law abiding physicians who treat chronic pain patients don’t end up going through what you are.
I only wish there was something more to be done to help you and all the other physicians who are so bravely advocating for your patients. Today it’s chronic pain patients who suffer…who knows who it will be next? And where it will end?…
Regards,
K

Emily Ullrich

Dr. Isben,

Thank you again for being one of the VERY FEW sensible, caring, humane doctors left, particularly for chronic pain patients, and even more specifically, thank you for speaking out about the ongoing abuse of Medicaid patients in pain. Also, thank you for encouraging Medicaid patients to speak out! I am a chronic pain patient on Medicaid, who has been astonished at the blatant and open discrimination of Medicaid patients in pain. We need more doctors like you, I speak out every chance I get, but mostly to the dismay and dismissal of medical and government officials. I will continue to speak out, and continue to support and be uplifted by doctors like you!

Hope you beat the rap. Inadequate record keeping means whatever they want it to mean, and anyone who’s under that kind of scrutiny can be found to keep inadequate records at any time.

BL

There is nothing new about this, unfortunately. There are several reasons, although I call them excuses, for this treatment. But, you are correct that if these patients had private insurance or money their treatment would never be accepted.

One of the reason is that Medicaid Patients are listed as abusing and misusing drugs more than others. Another reason is because the Washington D.C. politicians want to know what Disciplinary Actions states take when it comes to high Medicaid providers who are high prescribers of pain meds and certain other meds.

The fact that many who receive Medicaid also receive SSI and have painful debilitating conditions seems to have been lost. In Louisiana Medicaid will not pay for the management of chronic pain. Pain Management Clinics will not take it. PCP’s and other drs tell their Medicaid patients they need pain management. Even LSU Hospital in north Louisiana won’t rx pain meds to chronic pain patients, although they will give referrals. The problems is that if you receive Medicaid your have little to no income, even if you receive SSI. Plus it is extremely difficult to find a pain management dr who will accept cash.

Transportation to and from medical appointments are a Mandatory Medicaid Benefit. Vicky should be able to use Medicaid Non Emergency Transportation to get to her drs appointments.