Does DEA go after legitimate Pain docs?

[emd123]

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1- I am currently considering applying this spring for accredited pain fellowships. Should someone who wants to do a fellowship and practice ethical and legitimate pain management fear unfair DEA persecution/prosecution? In other words, could a legitimate Pain physician become collateral damage of the pill mill crackdown because of one or two bad apple patients?

2- Also, would it be possible to run a totally non-narcotic pain clinic or is that completely a total pipe-dream?

 

[Doctodd]

1. no...but since this question is really 2 questions, id say yes it is certainly possible to be collateral damage

2. yes if you have the say in the practice

 

[emd123]

1. no...but since this question is really 2 questions, id say yes it is certainly possible to be collateral damage

2. yes if you have the say in the practice

...what type of "collateral damage"? I'd like to think if you're running an honest practice you wouldn't have to worry.

 

[Jeff05]

1- I am currently considering applying this spring for accredited pain fellowships. Should someone who wants to do a fellowship and practice ethical and legitimate pain management fear unfair DEA persecution/prosecution? In other words, could a legitimate Pain physician become collateral damage of the pill mill crackdown because of one or two bad apple patients?

2- Also, would it be possible to run a totally non-narcotic pain clinic or is that completely a total pipe-dream?

DEA will not go after you if you do the right thing - document and treat along accepted practice standards, no matter how much oxycontin you write for.

At this time in pain management - unless you are in a completely underserved/unsaturated area or have a phenomenal referral base that JUST sends you procedures, you WILL have to write for xanax/opioid/muscle relaxant, etc. otherwise, NO ONE will send you ANY patients.

 

[PMR 4 MSK]

At this time in pain management - unless you are in a completely underserved/unsaturated area or have a phenomenal referral base that JUST sends you procedures, you WILL have to write for xanax/opioid/muscle relaxant, etc. otherwise, NO ONE will send you ANY patients.

WRONG!

I write for xanax about 3 times a year - 1/2 to 1 mg x 1 pill for an MRI in a claustrophobic pt. You should NEVER feel like you have to write for a drug that is inappropriately prescribed for 90% of the people who take it. Xanax has almost no place in pain management.

Similarly muscle relaxants - I'll write for Flexeril or Robaxin for acute MSK injuries for 2-4 weeks, never for chronic pain and never Soma. Soma is nothing but a benzo in sheeps clothing.

If you find yourself writing vicodinsomaxanax ever, you will have just invited every single drug seeker in a 200 mile radium into your clinic.

And I'm not in an underserved area nor do I have the referral base you describe.

Never feel like you have to prescribe something against your better judgement just because you might lose a referring source. That's the death knell of your dignity and practice.

 

[lobelsteve]

DEA will not go after you if you do the right thing - document and treat along accepted practice standards, no matter how much oxycontin you write for.

At this time in pain management - unless you are in a completely underserved/unsaturated area or have a phenomenal referral base that JUST sends you procedures, you WILL have to write for xanax/opioid/muscle relaxant, etc. otherwise, NO ONE will send you ANY patients.

Hey stoop, can you post your website, there are 1000's of addicts looking for docs like you. You sound like a dumping ground.

 

[knoxdoc]

At this time in pain management - unless you are in a completely underserved/unsaturated area or have a phenomenal referral base that JUST sends you procedures, you WILL have to write for xanax/opioid/muscle relaxant, etc. otherwise, NO ONE will send you ANY patients.

I don't write them. I don't work in an underserved area and I don't have that referral base. I am also willing to give up pay in order to have a practice I can have some dignity about (I'm not making any statements about your practice). Those docs who won't send you patients under such circumstances are only looking to dump. I don't want those patients - I'd rather go home early and play with the kids and eat Little Caesars for dinner (like tonight).

I think of my practice as a limited menu: "here is what I have to offer you." Patients don't have to like it or agree with it. If they think it sucks, they can go elsewhere.

 

[Jeff05]

i wish that was the case. no prescriptions for opioids...however, in saturated markets - nyc/north jersey/places in california, etc: you are EXPECTED by referral sources to manage opiates, if necessary. perhaps, not benzos, as much. you can manage the responsibly. but, there is NO SUCH thing, here, as "i don't write scripts..."

i'm not saying that you will be a dumping ground and a pill mill. however, within reason, you will have to manage pharmacology. that's a part of being a pain doctor. can you imagine an interventional cardiologist refusing to write for beta blockers?

if you don't do it - there are so many people that will AND who do procedures that you will NOT have ANY referrals.

so, to the original poster - and i'm just a fellow here, but after interviewing EVERYWHERE in my area and working at multiple institutions during fellowship, i have not met or heard of ONE pain physician who has a practice in which he/she does not write any prescriptions. i suppose, the answer is that if you would like to have that sort of practice, you will be geographically limited.

i agree, that benzos are not warranted except for certain cases - MRI for claustrophobic patient, for ex.

 

[Jcm800]

DEA will not go after you if you do the right thing - document and treat along accepted practice standards, no matter how much oxycontin you write for.

At this time in pain management - unless you are in a completely underserved/unsaturated area or have a phenomenal referral base that JUST sends you procedures, you WILL have to write for xanax/opioid/muscle relaxant, etc. otherwise, NO ONE will send you ANY patients.

You are incorrect sir!

I dont have a single oxycontin patient, i dont have a single xanax or benzo patient, i dont have a single soma patient...i write prescriptions all day long, but not what the patients or the dumping PCPs necessarily want...

most pain docs write scripts, but we dont necessarily have to write and manage someones dump opiods/benzo.

I am very stingy with opiods, but when appropriate i have no problem doing. Problem is, its almost never appropriate, IMHO. Just today, 67 year old lady, with whatever problem she has been on opiates for a long time, UDS positive for THC...
im not gonna continue to write that script (technically i never did, it was my partners patient, but it doesnt really matter for argument purposes)

 

[Ligament]

At this time in pain management - unless you are in a completely underserved/unsaturated area or have a phenomenal referral base that JUST sends you procedures, you WILL have to write for xanax/opioid/muscle relaxant, etc. otherwise, NO ONE will send you ANY patients.

I disagree with this statement. It might be true for many cases but not all...I never write for nor recommend benzos and maybe 1x per year muscle relaxants. I do write for and recommend opioids on very select patients but feel no pressure to do so...I do it cause that is what I feel is best for patient care.

I NEVER assume the prescription of opioids on a new patient. Patients are told they will no receive opioid prescriptions on the first visit. (of course if it is a malignant pain generator I'll write for it but never for benign pain).

 

[knoxdoc]

I am very stingy with opioids, but when appropriate i have no problem doing. Problem is, its almost never appropriate, IMHO.

Couldn't agree more.

 

[Mister Mxyzptlk]

I don't think there would be much interest in the typical pain doc. You really have to work hard to attract attention.

OTOH, pretty much every guy I have ever read about who is in jail or lost his license for over-prescribing swears he was a legitimate pain doctor.

 

[stim4u]

This thread is very interesting to me, as there appears to be some bipolar philosophies out there. Most of us are interventionalists that offer a wide range of options from acupuncture to pain pumps. And most of us are pretty conservative when it comes to opioid management. But if you are caring for a LARGE subset of patients, as I do, with cancer, numerous failed back surgeries, arachnoiditis, peripheral nerve injuries, etc. how can you NOT offer opioid therapies on occasion..... clearly short acting opioids and xanax, etc are poor choices, but we are talking about legit chronic neuropathic pain patients for the most part.

Also for chronic muscle spasm that have failed everything, baclofen and klonipin have some role. So Jeff 05 I agree with most of this thread, but clearly the members are making an example of you, and opioid therapies are an appropriate option in the right patient. Just don't prescribe meds for referrals because it will bit you in the ass later.

 

[lobelsteve]

This thread is very interesting to me, as there appears to be some bipolar philosophies out there. Most of us are interventionalists that offer a wide range of options from acupuncture to pain pumps. And most of us are pretty conservative when it comes to opioid management. But if you are caring for a LARGE subset of patients, as I do, with cancer, numerous failed back surgeries, arachnoiditis, peripheral nerve injuries, etc. how can you NOT offer opioid therapies on occasion..... clearly short acting opioids and xanax, etc are poor choices, but we are talking about legit chronic neuropathic pain patients for the most part.

Also for chronic muscle spasm that have failed everything, baclofen and klonipin have some role. So Jeff 05 I agree with most of this thread, but clearly the members are making an example of you, and opioid therapies are an appropriate option in the right patient. Just don't prescribe meds for referrals because it will bit you in the ass later.

I disagree with the use of BZD for any painful condition. Baclofen is not a BZD.

I think that if they have spasticity issues and they "need" a BZD then they need a spasticity doc and not a pain doc. Separating the BZD from the opiate is of paramount importance from a legal and regulatory standpoint. And no, I don't have a badge.

 

[lonelobo]

I disagree with the use of BZD for any painful condition. Baclofen is not a BZD.

I think that if they have spasticity issues and they "need" a BZD then they need a spasticity doc and not a pain doc. Separating the BZD from the opiate is of paramount importance from a legal and regulatory standpoint. And no, I don't have a badge.

Not sure what a spasticity doc is?
But obviously true spasticity is often very painful, I do see a few of these pts
mixed into my practice(CVA with new dx of lumbar radiculopathy).

I believe those of us with PMR background should be able to handle these
issues in the realm of pain mgmt.

 

[lobelsteve]

Not sure what a spasticity doc is?
But obviously true spasticity is often very painful, I do see a few of these pts
mixed into my practice(CVA with new dx of lumbar radiculopathy).

I believe those of us with PMR background should be able to handle these
issues in the realm of pain mgmt.

I do as well. The only patient I ever saw benefit from Valium for spasticity was inpatient PMR for MS. 28 y/o AAM who needed a baclofen pump. He died from complications of MS before getting that far in care.

I do not believe in the use of chronic BZD's for any condition, but understand their use for short term panic attacks, reactive anxiety, and pre-procedural. If a patient would benefit from spasticity mgmt with BZD- I refer them to a Neurologist or other PMR doc.

As drusso puts it: I am a Phino- Physiatrist in name only.

 

[Tenesma]

i have yet to see a patient on chronic benzos have any real sort of pain/spasm/spasticity/neuropathic control....

 

[drusso]

As drusso puts it: I am a Phino- Physiatrist in name only.

Is PLEASE a risk factor for becoming a Phino?

http://forums.studentdoctor.net/showpost.php?p=7522965&postcount=4

 

[PMR 4 MSK]

I do not believe in the use of chronic BZD's for any condition, but understand their use for short term panic attacks, reactive anxiety, and pre-procedural. If a patient would benefit from spasticity mgmt with BZD- I refer them to a Neurologist or other PMR doc.

By "old school" teaching, Valium was always indicated for use in spasticity due to it's perceived effects on the spinal cord and other descending pathways. The general CNS depressent effect and abuse potential were always ignored and many SCI patients left rehab on Valium 10 mg TID, even those who were there from accident due to drug or alcohol intoxication (~50% of the pts). I never agreed with that, but the patients fought tooth-and-nail for it.

 

[lobelsteve]

Is PLEASE a risk factor for becoming a Phino?

http://forums.studentdoctor.net/showpost.php?p=7522965&postcount=4

Ignoring the early signs of becoming a doorknob, doormat, etc are indeed risk factors.

I find tequila to be quite useful in fending off this disabling condition, but Valium has no effect.

 

[ceced]

There is a great site to visit if you want to find out what leading pain management experts have to say about DEA and prescribing opioids in your pain management practice www.emergingsolutionsinpain.com. Registration is free--its a multi-supported, non-branded site. Under Tools tab on the homepage, the site lists a tool kit that talks about pain assessment, monitoring and best practices. You can also search DEA and prescribing opioids as they have content (expert commentaries, education) that addresses this very topic. Hope you find this useful.

 

[lonelobo]

There is a great site to visit if you want to find out what leading pain management experts have to say about DEA and prescribing opioids in your pain management practice www.emergingsolutionsinpain.com. Registration is free--its a multi-supported, non-branded site. Under Tools tab on the homepage, the site lists a tool kit that talks about pain assessment, monitoring and best practices. You can also search DEA and prescribing opioids as they have content (expert commentaries, education) that addresses this very topic. Hope you find this useful.

By "Leading pain management experts", I suppose you are referring to the Shills for the Pharma Companies?

 

[lobelsteve]

By "Leading pain management experts", I suppose you are referring to the Shills for the Pharma Companies?

100% agree.

By experts, it means they get paid several thousands to tens of thousands to promote REMS (and high dose brand name opioids).

 

[Mister Mxyzptlk]

Clonazepam QHS kicks ass for restless legs. Other than that I don't prescribe many benzos.

I am not interested in what "leading experts" say simply because I know and have worked with law enforcement officers on drug issues. I have one coming in for a meeting tomorrow to discuss Medicaid fraud.

I have often mentioned NADDI (www.naddi.org) but as far as I can tell nobody here has ever joined. Membership is cheap. Join up and go to a couple of NADDI conferences. See what they are concerned about and what they look for in a physician's practice, then don't do those things.

One thing you learn is how pitiful their budgets are. They can only cut the tallest blades of grass because they are only given scissors. From the comments I've read on this board I would be astonished if anyone was in any jeopardy. In all likelihood you have already been scanned at least once anyway in the DEA database.

 

[Aether2000]

Read the fine print at the bottom of the page for emergingpainsolutions:

ESP would like to acknowledge independent educational grants from
Cephalon, Inc., Endo Pharmaceuticals, PriCara®, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., and Purdue Pharma L.P.

 

[stim4u]

For the record, the true mechanism of action for baclofen is not fully understood. It binds pre and post synaptic neurons at the GABA-B receptor site and associated calium channels. Benzo typically bind to GABA-A. whether it is considered a true benzo or not, is semantics in my book. Not that I advocate baclofen for acute/chronic spasms, there is a role for its use, whether your are PMR 'spacticity doctor' or not 🙂

"Baclofen is a derivative of gamma-aminobutryic acid (GABA) and is believed to inhibit mono and polysynaptic reflexes at the spinal level. Treatment with baclofen was compared to placebo in a double blind, randomized study of 200 patients with acute low back pain. Patients with initially severe discomfort were found to benefit from baclofen, 30- to 80-mg daily, on days four and ten of follow up. Forty-nine percent of treatment patients complained of sleepiness, 38% of nausea, and 17% discontinued treatment."

 

[Mister Mxyzptlk]

Read the fine print at the bottom of the page for emergingpainsolutions:

ESP would like to acknowledge independent educational grants from
Cephalon, Inc., Endo Pharmaceuticals, PriCara®, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., and Purdue Pharma L.P.

In other words, "We are desperately trying to make you as comfortable as possible prescribing our products in the hope that you will prescribe even more."

 

[PMR 4 MSK]

There is a great site to visit if you want to find out what leading pain management experts have to say about DEA and prescribing opioids in your pain management practice www.emergingsolutionsinpain.com. Registration is free--its a multi-supported, non-branded site. Under Tools tab on the homepage, the site lists a tool kit that talks about pain assessment, monitoring and best practices. You can also search DEA and prescribing opioids as they have content (expert commentaries, education) that addresses this very topic. Hope you find this useful.

Can I have some cheese and crackers with the spam?

 

[geauxg8rs]

Can only have green eggs and guvment cheese with your spam.

 

[lobelsteve]

For the record, the true mechanism of action for baclofen is not fully understood. It binds pre and post synaptic neurons at the GABA-B receptor site and associated calium channels. Benzo typically bind to GABA-A. whether it is considered a true benzo or not, is semantics in my book. Not that I advocate baclofen for acute/chronic spasms, there is a role for its use, whether your are PMR 'spacticity doctor' or not 🙂

"Baclofen is a derivative of gamma-aminobutryic acid (GABA) and is believed to inhibit mono and polysynaptic reflexes at the spinal level. Treatment with baclofen was compared to placebo in a double blind, randomized study of 200 patients with acute low back pain. Patients with initially severe discomfort were found to benefit from baclofen, 30- to 80-mg daily, on days four and ten of follow up. Forty-nine percent of treatment patients complained of sleepiness, 38% of nausea, and 17% discontinued treatment."

Baclofen is not a drug of abuse.

Baclofen MOA:

Stimulates GABAB receptors
Reduces Ca2+ influx into synaptic terminal to reduce release of excitatory neurotransmitters

 

[teri78]

How did baclofen get lumped into a discussion about benzos and drugs of abuse. Like others have said baclofen is not a benzo. It binds the gaba-B receptors, ulike benzos that bind gaba-A receptors. It may also have some effect on Ca channels.

It tends to play a large role in spasticity due to multiple sclerosis, especially intrathecally. It also can be beneficial in the treatment of neuropathic pain. However, it is probably better delivered intrathecally to decrease the significant side effects it can cause. Although it is not really considered a drug of abuse, it probably has a small amount of abuse potential due to its sedative properties. However, it cannot be much, because I don't recall ever hearing about it being sold on the street.

 

[Jcm800]

I do as well. The only patient I ever saw benefit from Valium for spasticity was inpatient PMR for MS. 28 y/o AAM who needed a baclofen pump. He died from complications of MS before getting that far in care.

I do not believe in the use of chronic BZD's for any condition, but understand their use for short term panic attacks, reactive anxiety, and pre-procedural. If a patient would benefit from spasticity mgmt with BZD- I refer them to a Neurologist or other PMR doc.

As drusso puts it: I am a Phino- Physiatrist in name only.

AINO doesnt sound too good (anesthesiologist in name only)

 

[drusso]

AINO doesnt sound too good (anesthesiologist in name only)

That's too funny. Better keep it away from your OR-based colleagues...