After this month, Ohio requires some form of pain boards

[myrandom2003]

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For anyone interested, I received an email from the state medical assoc for running pain clinics:

Final Pain Management Clinic Licensure Rules include Grandfathering Clause – License Application Deadline is June 20
In accordance with House Bill 93, the State Medical Board of Ohio finalized its emergency rules on the standards for owning and operating a pain management clinic. Based on the leadership and recommendations of the Ohio State Medical Association (OSMA) Prescription Drug Abuse Committee, the OSMA worked with the Medical Board to address several concerns regarding the potential impact the draft rules had on access to care for chronic pain patients as well as the potential impact the rules would have on legitimate pain physicians currently practicing without subspecialization in pain medicine.

As a result of the OSMA’s efforts of working with the Medical Board, the requirement that a pain management clinic owner must have hospital privileges was removed and several amendments were adopted, including:
Establishing a limited grandfathering clause for non-board certified pain physicians that have provided full-time clinical services for the last three years in pain medicine, pain management, hospice and palliative medicine, addiction psychiatry, physical medicine and rehabilitation, occupational medicine or rheumatology. The grandfathering clause sunsets on June 20. (see summary below for full explanation of this amendment)
Requirement that all pain management clinic owners, operators and physicians providing care at the clinic are required to complete 20 hours of Category I continuing medical education (CME) in pain medicine every two years.
Allowing any physician to provide care at a pain management clinic under the direction, supervision and control of the physician owner.

Grandfathering Clause – Qualifications and Application Deadline
Qualifications – Full-time clinical services for the last three years in pain medicine, pain management, hospice and palliative medicine and addiction psychiatry, physical medicine and rehabilitation, occupational medicine or rheumatology. While many specialties are not specifically listed, the rule should be read to include all physicians currently providing pain medicine that meet the definition of a pain management clinic (a majority of your patients are prescribed controlled substances for the treatment of pain that is expected to last more than 30 days).
Onsite inspection of the facility by the Medical Board – Physician applicants under the grandfathering clause are required to submit to an onsite inspection by the Medical Board to determine whether the practice is complying with the minimum standards of care established in the law and rule.
Application Deadline Expires on June 20, 2011 – Physicians must apply to the State Board of Pharmacy for a pain management clinic license by June 20 to be eligible for the grandfathering clause.
Any physician that fails to apply for a pain management clinic license after June 20 will be required to have current subspecialty board certification in pain medicine or hospice and palliative care or board certification by the American Board of Pain Medicine or the American Board of Interventional Pain Physicians.
These amendments will permit pain physicians who have been providing care to chronic pain patients for three continuous years to apply for pain management clinic ownership. The rules strike a balance between enhancing the standards of pain medicine in Ohio and preserving access to care for patients being treated by physicians who have extensive experience in their care, but are not subspecialty board certified pain physicians. The pain medicine CME requirements will ensure all physicians providing care in pain management clinics are educated on the latest medical advances and treatment methods in their field.

The OSMA would like to thank the State Medical Board for resolving these important issues, specifically Mike Miller, Rick Whitehouse, Kim Anderson and Sallie Debolt. We greatly value the Board’s hard work and understanding of the delicate balance of cracking down on rogue physicians operating pill mills and the need to preserve access to care for chronic pain patients.

Please click here for a complete copy of the Medical Board’s Rule, Ohio Administrative Code 4731-29-01, Standards and Procedures for the Operation of a Pain Management Clinic. It is imperative that you read the rule carefully to determine whether or not your practice qualifies as a pain management clinic. If you do qualify, please click here to visit the Ohio State Board of Pharmacy’s website and download the application for pain management clinic licensure. Again, you must apply for a license with the Board of Pharmacy by June 20 otherwise face severe criminal and civil penalties.

If any OSMA member has any additional questions or needs additional information on this issue, please contact Jeff Smith at [email protected] or (614) 527-6740 or Jennifer Hayhurst at [email protected] or (614) 527-6766. For more information on this issue from the OSMA, visit www.osma.org/prescriptiondrugabuse.

As Ohio’s largest and oldest statewide physician organization, the OSMA has been actively involved in advocating for Ohio’s physicians and their patients on this issue. The efforts of the OSMA on the implementation of HB 93 represent just one of the many ways in which the OSMA works every day for physicians and patients in our state. For more information about the OSMA, please visit www.osma.org/membership.

 

[knoxdoc]

"a majority of your patients are prescribed controlled substances for the treatment of pain that is expected to last more than 30 days"

How are they defining "controlled substance"? Does that mean that prescribing Naproxen 500mg to more than 50% of patients is considered "pain management". There are going to be a ton of family doctors who will not be able to give NSAIDS to OA patients. Other that that, I like it.

 

[PMR 4 MSK]

ABPMed certification is easy to get, no fellowship required.

 

[lobelsteve]

"a majority of your patients are prescribed controlled substances for the treatment of pain that is expected to last more than 30 days"

How are they defining "controlled substance"? Does that mean that prescribing Naproxen 500mg to more than 50% of patients is considered "pain management". There are going to be a ton of family doctors who will not be able to give NSAIDS to OA patients. Other that that, I like it.

Since when did naproxen become scheduled?

I think you misread. Opiates, lyrica, sleepers are our controlled substances. Psychiatry has their controlled meds as stimulants and benzos.

 

[nvrsumr]

ABPMed certification is easy to get, no fellowship required.

Exactly. This was a reasonable thing to get before there was an ABMS subspecialty. Plus most of these docs had the opportunity to grandfather into ABMS with a 1/2 day test.

Why allow the dilution of "board certification" for our specialty alone. I havent heard of any alternative cardiology boards..... I cant believe this is statutory law. Just window dressing making the public think they are getting something they are not-A board certified physician.

 

[knoxdoc]

Yup, I misread that. Still, though, plenty of FPs are prescribing tramadol, lyrica, T#3, etc on a chronic basis (let alone schedule II meds). This will either 1) not allow them to do so or 2) scare them away from pursuing the necessary board training/grandfathering due to the increased risk and scrutiny of being considered a "pain doc". That could lead to a huge number of patients being dumped on pain docs in Ohio. I can't see how they will be able to manage everyone.

 

[myrandom2003]

At one point they were also considering to limit prescribers 2000 doses in a 30 day period for schedule 2 meds. (where QID would be 4doses/day), unless they had special registration. I think that one is still being debated.

This is all stemming from an increase in prescription drug deaths in ohio the last few of years.

I agree this is going to increase the number of patients on pain clinics, however, it hopefully cuts down on the "my doctor gave me enough vicodin/percocet/etc to last till i get to your appointment."

 

[PMR 4 MSK]

That could lead to a huge number of patients being dumped on pain docs in Ohio. I can't see how they will be able to manage everyone.

Stop handing out opioids to everyone simply because someone else gave them to them. Just because the PCP put them on Percocet 10s 4 QID does not mean I have to continue it, prescribe OxyContin 80 BID, or any similar Rx.

"I'm sorry, we are unable to accomodate this patient" in response to the referral. Repeat ad nauseum.

I try not to attempt to kill or control monsters I did not create.

Alternatively, "I recommend we wean you off these opioids and start some PT, do a LESI, trial some gabapentin, etc." Then let them drive down to Florida for their drug supplies, because they (thankfully) will not come back to you..

 

[ghost dog]

"a majority of your patients are prescribed controlled substances for the treatment of pain that is expected to last more than 30 days"

How are they defining "controlled substance"? Does that mean that prescribing Naproxen 500mg to more than 50% of patients is considered "pain management". There are going to be a ton of family doctors who will not be able to give NSAIDS to OA patients. Other that that, I like it.

From reading the opening post, it seems that opioid prescriptions and chronic pain is managed very differently in the US, as compared to Canada (my neck of the woods).

In Canada, any physician (whether it by Family practioner, Internist, etc.), can dispense long acting opioids on an indefinite basis.

I have heard rumours that family docs in the U.S are not allowed to do so?

Is there some sort of daily Morphine mg ceiling ( or equipotent )equivalent ?

I would think that this highly impractical, considering the number of pain docs, and the number of chronic pain patients. Lawmakers gone wild.

When I have stabilized a patient's pain, I then refer them back to their primary care doc for ongoing scripts. Are you supposed to script every single patient , you have ever seen, FOREVER?

 

[myrandom2003]

I received an explanation letter today, probably due to the number of physician complaints and questions.

Apparently Rule 93 ONLY applies to you if you are prscribing scheduled subs, including tramadol, for MORE than 50% of the people you see in any given month.

This only applies to chronic long term pain management with controlled substances and does not apply to acute short term pain management.

This is because various surgical subspecialities (like ortho, plastics, gen surg etc) sometimes write over 50% narcotics to manage their patients perioperative short term acute pain.

But if you are an employee of a pain clinic you apparently don't need to be boarded because only the Physician owner of the practice has to be boarded.

 

[PMR 4 MSK]

From reading the opening post, it seems that opioid prescriptions and chronic pain is managed very differently in the US, as compared to Canada (my neck of the woods).

In Canada, any physician (whether it by Family practioner, Internist, etc.), can dispense long acting opioids on an indefinite basis.

I have heard rumours that family docs in the U.S are not allowed to do so?

Is there some sort of daily Morphine mg ceiling ( or equipotent )equivalent ?

I would think that this highly impractical, considering the number of pain docs, and the number of chronic pain patients. Lawmakers gone wild.

When I have stabilized a patient's pain, I then refer them back to their primary care doc for ongoing scripts. Are you supposed to script every single patient , you have ever seen, FOREVER?

No law preventing family docs in the US on a Federal level, but several states have, and/or are implimenting similar style rules. See the previous posts a couple months ago on the State of Washington.



"Are you supposed to script every single patient , you have ever seen, FOREVER?"

Many PCPs would like it that way - "You're the pain doc, you write for the pain pills." Many pain docs agree with this. Many more don't. It's a battle ground of Hot Potatoe.

 

[mille125]

From reading the opening post, it seems that opioid prescriptions and chronic pain is managed very differently in the US, as compared to Canada (my neck of the woods).

In Canada, any physician (whether it by Family practioner, Internist, etc.), can dispense long acting opioids on an indefinite basis.

I have heard rumours that family docs in the U.S are not allowed to do so?

Is there some sort of daily Morphine mg ceiling ( or equipotent )equivalent ?

I would think that this highly impractical, considering the number of pain docs, and the number of chronic pain patients. Lawmakers gone wild.

When I have stabilized a patient's pain, I then refer them back to their primary care doc for ongoing scripts. Are you supposed to script every single patient , you have ever seen, FOREVER?

Any prescriber can right for opioids if he or she wants to. Sometimes PCP's may tell patients this in order to escape from writing the script. In Texas schedule II requires a special pad that you have to buy. Some docs dont buy the scripts and then can honestly tell patients that they are not able to write for schedule II's. If you ask me this is all a cop out. Be the doctor and tell the patient that you wont write the script if you dont think that it will benefit them.


Just this week I have been battling with a PA in an oncology clinic. One of the long term doctors in the clinic has moved and the PA was hired to pick up the slack. He actually refused to write pain meds for several mutual patients with active cancer saying that it was not in his job description. I yelled at him and told him to go back to seeing sore throats.


It seems that we have very few docs who engage in responsible prescribing. It seems that most docs either dont write any scripts or go overboard and write far too many (just had 900 mg of oxycodone per day from doctor in Hawaii). These are two extremes and I feel that it is downright shameful. I am not picking on Tenesma but I am going to rehash what he said earlier. If 10% of chronic pain patients need to be on opioids then why would you or the PCP refuse to right it. I dont get it. Again, I am not picking on Tenesma but his words/actions are utilized by a lot of docs.....

 

[PMR 4 MSK]

It seems that we have very few docs who engage in responsible prescribing. It seems that most docs either dont write any scripts or go overboard and write far too many (just had 900 mg of oxycodone per day from doctor in Hawaii).

He's still doing that, eh?

 

[ghost dog]

He's still doing that, eh?

900 mg of Oxycodone a day? That's ridonculous.

I used to have a doc around my neck of the woods who would do that, until he had his opioid / narc license yanked.

The reason? I believe that a number of unrelated institutions complained about him:

1. Pharmacists.
2. Addiction counsellors / sober living housing.

I saw so many of this guy's patients on crazy high doses , plus a positive UDS for cocaine, I felt compelled to report him to the College.

I initially conveyed my concerns to him first, but he didn't seem to think his practice patterns were out of the norm.

Ok: Oxycontin 120 mg 6x / day is par for the course? For chronic mechanical back pain?

With every patient of yours I see having a positive cocaine?

You've got a bad rep. 😱

 

[101N]

http://en.wikipedia.org/wiki/William_Hurwitz

He's in prison, where he should be. Sounds like the guy in Hawaii may be a future cell mate.

 

[painstop]

http://en.wikipedia.org/wiki/William_Hurwitz

He's in prison, where he should be. Sounds like the guy in Hawaii may be a future cell mate.

Looks like some drug seeker decided to add a little info to the end of the wikipedia article on this guy about the "effect on patients"...sheeesh

 

[PMR 4 MSK]

Looks like some drug seeker decided to add a little info to the end of the wikipedia article on this guy about the "effect on patients"...sheeesh

Probably the "patient" himself.

 

[101N]

It is amazing to me the sympathy afforded to this idiot in the press - NYT. This is not Albert Scheitzer, this is an unrepentant drug trafficker who continues to defend his behavior from the jail cell.

Hurwitz is what you get when you apply cancer pain principles - no ceiling for opioids, pain is whatever the patient says it is, pseudoaddiction - to non-malignant pain.

 

[mid|ine]

no ceiling for opioids, pain is whatever the patient says it is

This is actually and unfortunately the norm, being taught at fellowships around the country. The expectation of many PCPs is exactly this, though they don't want to do it themselves.

The tide is turning, but its slow.

The vast majority of chronic pain patients, IMHO, should NOT be on chronic narcotics. I have an even bigger problem with sustained release and / or high dose narcotics.

 

[Ligament]

Was Hurwitz really at fault, or was he targeted? I know of his case but no personal interactions with him or those who knew him. I do not know the details of his case. I try to keep in mind the goverment may try to persecute me or any one of you at any time for our use of opioids.

 

[PMR 4 MSK]

I had one of his patients come to see me. Lived 30 - 45 min from me, 12 hours from Dr. Hurwitz. Pt was a total nutbag. Had fallen while rock climbing, brought me pictures of a friend re-enacting the scene for the pictures. Told me repeatedly throughout the visit "You probably can't help me." Vague pains, old fractures but nothing else to blame all his pain on. Was on 2 LAOs, 2 SAOs and a benzo. MS equivalent of about 300 - 400 mg/day if I remember correctly.

Dr. Hurwitz's records were spurious, vague and often unhelpful. Reasons for med changes were often not found. Dosages upped when "The patient reports he is feeling well this month." No UDS, no real risk screening I could find. Some visits had no apparent documentation at all. Phone refills were common, as were early refills.

At the time, I did not even know who the doc was. I had to look him up to see why this guy was traveling so far to see him.

I ended the visit with, "You are correct, I cannot help you."

 

[101N]

I do not know the details of his case.

You need to read about this case. Sometimes juries get it right, even when our colleagues don't.

This case was the turning of the pendulum that we all speak about. Thank god it turned. But not soon enough to have prevented the current prescription drug epidemic.

 

[ghost dog]

It is amazing to me the sympathy afforded to this idiot in the press - NYT. This is not Albert Scheitzer, this is an unrepentant drug trafficker who continues to defend his behavior from the jail cell.

Hurwitz is what you get when you apply cancer pain principles - no ceiling for opioids, pain is whatever the patient says it is, pseudoaddiction - to non-malignant pain.

When I'm teaching med students and family practice residents, I always try to make the point that when treating chronic non malignant pain with opioids the ceiling dose should be your COMMON SENSE (the italics are capitalized / bolded in the power point slide). Along with the fact that opioids have their best effect at initiating doses, with diminishing returns at higher doses.

But I guess these type of cases go to show, common sense ain't so common.

 

[101N]

Portnoy, the source of the epidemic.

By JOHN TIERNEY
Published: March 27, 2007
ALEXANDRIA, Va., March 26 — The case of the United States v. William Eliot Hurwitz, which began in federal court here on Monday, is about much more than one physician. It’s a battle over who sets the rules for treating patients who are in pain: narcotics agents and prosecutors, or doctors and scientists.



Dr. Hurwitz, depending on which side you listen to, is either the most infamous doctor-turned-drug-trafficker in America or a compassionate physician being persecuted because a few patients duped him.

When Dr. Hurwitz, who is now 62, was sent to prison in 2004 for 25 years on drug trafficking and other charges, the United States attorney for Eastern Virginia, Paul J. McNulty, called the conviction “a major achievement in the government’s efforts to rid the pain management community of the tiny percentage of doctors who fail to follow the law and prescribe to known drug dealers and abusers.”

Siobhan Reynolds, the president of an advocacy group called the Pain Relief Network, hailed Dr. Hurwitz’s singular dedication and compared his plight to Galileo’s. Some of the country’s foremost researchers in pain treatment and addiction supported his appeal for a retrial, which was ordered because the jury in the first case was improperly instructed to ignore whether Dr. Hurwitz had acted in “good faith.” These scientists say they are upset by how their research has been distorted by prosecutors in this case, and suppressed by the Drug Enforcement Administration in its campaign against the misuse of OxyContin and other opioid painkillers.

In the first trial, the prosecution accused Dr. Hurwitz of crossing the line from doctor to trafficker by prescribing irresponsibly high doses of painkillers to his patients in the Virginia suburbs of Washington. He was accused of ignoring blatant “red flags” or signs that some patients were misusing or selling the drugs. That is an emotionally powerful argument for a jury: warning signs can seem perfectly clear with the benefit of hindsight.

But to researchers who study deceptive patients, there is no such thing as a blatant red flag. Deception is notoriously difficult to spot, as Dr. Beth F. Jung and Dr. Marcus M. Reidenberg of Cornell University document in a new survey of the literature. They note, for starters, an experiment showing that even police officers and judges — ostensibly experts at detecting fraud — do no better than chance at detecting lying.

Doctors are especially gullible because they have a truth bias: they are trained to treat patients by trusting what they say. Doctors are not good at detecting liars even when they have been warned, during experiments, that they will be visited at some point by an actor faking some condition (like back pain, arthritis or vascular headaches). In six studies reviewed by the Cornell researchers, doctors typically detected the bogus patient no more than 10 percent of the time, and the doctors were liable to mistakenly identify the real patients as fakes.

When treating people with chronic pain, doctors have to rely on what patients tell them because there is no proven way to diagnose or measure it. Also, there is no standard dosage of medicine: A prescription for opioids that would incapacitate or kill one patient might be barely enough to alleviate the pain of another.

During the first trial, the prosecution argued that it was beyond the “bounds of medicine” for Dr. Hurwitz to prescribe more than 195 milligrams of morphine per day, but dosages more than 60 times that level are considered acceptable in a medical textbook. The prosecution’s supposedly expert testimony on dosage levels and proper pain treatment for drug addicts was called “factually wrong” and “without foundation in the medical literature” in a joint statement by Dr. Russell K. Portenoy and five other past presidents of the American Pain Society.

Dr. Portenoy, the chairman of the pain medicine department at Beth Israel Medical Center, was one of the researchers who worked with the D.E.A. four years ago to draw up guidelines on pain medication for doctors and law enforcement officials. The guidelines assured doctors that they would be safe unless they “knowingly and intentionally” prescribed drugs for illegitimate reasons, and cautioned narcotics agents not to investigate doctors just because they prescribed large quantities.

The D.E.A. published the guidelines, and then abruptly withdrew them on the eve of Dr. Hurwitz’s trial, just after his defense had indicated that it planned to use the document at the trial. The D.E.A., which said the document had not been properly vetted, went on to repudiate some of the guidelines and warned that it intended to keep targeting doctors deemed suspicious because they prescribed large quantities and ignored certain red flags.

Dr. Portenoy, who is to be a witness for Dr. Hurwitz at the retrial, has been one of the pioneers in identifying the risks of prescribing opioids. He says the warning signs that seem so obvious to prosecutors rarely offer clear guidance to doctors. When a patient keeps asking for refills because he runs out of his pills early, does that mean that he is a dealer or that he is not getting enough medication? If a urine test shows the presence of cocaine or other illegal drugs — as it did in some of Dr. Hurwitz’s patients — should a doctor automatically cut him off? That’s what some prosecutors and narcotics agents demand, but doctors realize that there are plenty of illegal drug users who also need pain relief.

“Half of pain patients would have to stop taking their medicine if the rule went out that every so-called red-flag behavior meant you couldn’t prescribe,” Dr. Portenoy says. He and researchers like Dr. Steven D. Passik, a psychologist at the Memorial Sloan-Kettering Cancer Center, have found that about half of pain patients exhibit at least a couple of the warning signs, and that even veteran physicians cannot agree on which signs are the most important to look for.

In a pretrial motion, Dr. Hurwitz’s lawyer, Richard A. Sauber, asked the court to bar the prosecution’s expert witnesses from using the red-flag argument because “it defies reason that any expert could testify” about something without “scientific support.” That motion was denied, however, so the flags may well be waving during the trial.

Even Dr. Hurwitz’s supporters acknowledge that he is not the ideal doctor to be the representative for the cause of pain patients. Although his expertise in pain medicine is well respected, some say he was gullible and reckless to the point of incompetence. But the traditional punishments for such mistakes are malpractice settlements and the loss of a state medical license, not a federal investigation and 25 years in prison.

“Doctors are trained to treat patients, not to be detectives,” says Dr. James N. Campbell, a Johns Hopkins University neurosurgeon specializing in pain, who will be another witness for Dr. Hurwitz. He says that doctors have already reacted to the D.E.A. crackdown by changing the way they deal with the many Americans — at least 50 million, by several estimates — who suffer from chronic pain.

“Opioids were a revolution in pain treatment during the 1990s, but doctors are now more reluctant to use them,” Dr. Campbell says. “If a doctor perceives there’s a 1 in 5,000 chance that a prescription will lead to a D.E.A. inquiry — just an inquiry, not even an arrest — he’s not going to take the chance. So the victims are the patients.”