Seattle Pill Mill Shut Down

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lobelsteve said:
http://www.seattlepaincenters.com/portfolio-item/frank-li-md/

Well trained. Greed? Got a few guys in Georgia heading in same direction he was practicing....
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"The deaths included Becky Gene Rae Kruse, 58, of Everett, a grandmother of three who had fibromyalgia and struggled most of her life with chronic pain and addiction. Kruse, who is listed as “Patient J” in the charges, died April 7, 2013, after an overdose of drugs including painkillers methadone, hydromorphone and tramadol, plus trazodone, an anti-anxiety medication, the charges state. Her daughter, Megan Sargent-Everett, 33, of Spokane, found Kruse collapsed on the bathroom floor, with the sink faucet still running, a police report said. Six days before her death, Kruse had filled a prescription for 90 4-milligram hydromorphone pills, also known as Dilaudid. It was written by an ARNP at the Everett Seattle Pain Centers clinic — which was within walking distance of Kruse’s apartment."

Reviewing their his website, I don't see one behavioral/mental health provider on staff any of his clinics. Making an appropriate diagnosis of OUD and rotating to buprenorphine could have made a difference. It likely would have improved her fibro too.

http://www.ncbi.nlm.nih.gov/pubmed/16148422
 
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Attached charges and orders from the WA state department of health. There could be a lot to learn from this case for residents, fellows, and those new to practice.
 

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  • Li_Order.pdf
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I can't bring myself to condemn this person based on what I've read. He had 8 clinics and a very heavy opioid population. Could it be that these overdose pts were taking HIGHER doses prior to seeing this doc and he was in the process of trying to wean them off? Would twice as many of these drug using pts have died if they weren't treated by him?

It seems like the board action was appropriate but I'm not gonna pile on. yet...
 
hyperalgesia said:
I can't bring myself to condemn this person based on what I've read. He had 8 clinics and a very heavy opioid population. Could it be that these overdose pts were taking HIGHER doses prior to seeing this doc and he was in the process of trying to wean them off? Would twice as many of these drug using pts have died if they weren't treated by him?

It seems like the board action was appropriate but I'm not gonna pile on. yet...
Click to expand...

16 known dead. Systematic failure. Also, kicked off panels for overbilling frequency of UDS for profit. But it gets worse if you read the pdfs.
 
hyperalgesia said:
I can't bring myself to condemn this person based on what I've read. He had 8 clinics and a very heavy opioid population. Could it be that these overdose pts were taking HIGHER doses prior to seeing this doc and he was in the process of trying to wean them off? Would twice as many of these drug using pts have died if they weren't treated by him?

It seems like the board action was appropriate but I'm not gonna pile on. yet...
Click to expand...

If you read the Board charges, it doesn't appear that there were well executed taper plans. Review of his website shows no behavioral health support---if you can afford 8 mid-levels, then you can afford at least a per diem addictionologist to help with the heavy lifting of the difficult patients. No mention of the use of naloxone education or buprenorphine either. I bet that all of these patients also had PCP's. I wonder if anyone attempted a "collegial conversation" about his prescribing practices before a career is ruined.

If you're within 150 miles of one of his clinics, expect a deluge of opioid refugees.
 
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In house utox, midlevels prescribing, 8 pill clinics(one in beverly hills) and a dozen deaths. The fact that he knew better and gamed the system to be a "pillonaire" just means he deserves jail time.
 
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My take on this case: if you are going to prescribe opioids medication regardless of your opioid treatment protocol, you should stay away from Medicaid population, at the minimum.

My own take on pain management, specifically opioid-based pain management and Medicaid population: they do NOT mix.
 
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If one wants to make a lot of money from narcotics:

1. Find as many medicaid patients as you can
2. Give them opioids
3. Opioid dependent medicaid patients feed in-house urine toxicology lab every visit
 
Stay small, efficient, and supervise everything. Don't let mid levels run wild. Happens everywhere. Guys are money hungry and it's both pmr and anesthesia And neurologists. It's a character issue, not necessarily a training issue.

One pain mid level is serving jail time in my state, the doctor is facing multiple wrongful death lawsuits. Just not worth the headaches. He wont be able to use his yacht and Bermuda home from jail...

These threads should be a wake up call for the next generation of pain medicine physicians... For sure...
 
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Stim4me said:
Stay small, efficient, and supervise everything. Don't let mid levels run wild. Happens everywhere. Guys are money hungry and it's both pmr and anesthesia And neurologists. It's a character issue, not necessarily a training issue.

One pain mid level is serving jail time in my state, the doctor is facing multiple wrongful death lawsuits. Just not worth the headaches. He wont be able to use his yacht and Bermuda home from jail...

These threads should be a wake up call for the next generation of pain medicine physicians... For sure...
Click to expand...

Shhh. Want ro follow the auction and get the house for cheap.
 
inhouse tox labs are only a recent enough development that has not gotten shut down.. yet. just like inhouse pharmacies.

medicaid does not make enough money to justify the time, money, headache, social discord, etc to focus on medicaid.
 
According to local television reports, his practice cared for 25,000 patients and 6,000 Medicaid patients. Without a systemic approach or hand-off, what percentage or these patients are at risk for turning to heroin, undergoing questionable surgeries? PCP's are very reluctant to prescribe opioids and WA state is very difficult to get buprenorphine prior-aurthed and paid as they require all patients be seen in community mental health centers.

Provider Alert
July 14, 2016


Effective July 14, 2016, Apple Health (Medicaid) is no longer contracting with Seattle Pain Centers and any prescribers working out of Seattle Pain Centers.
Many of the patients seen in this clinic are on high dose opioids.

The termination of SPC and its associated prescribers applies to Apple Health’s fee-for-service (FFS) program and managed care organizations (MCOs). The agency and its contracted MCOs will attempt to contact affected patients, but may not reach everyone. As a result of the termination, patients may present at your clinics or in emergency departments.

Prescriptions written by providers of SPC who have not had action taken on their licenses will continue to be paid by MCOs and FFS Medicaid for at least 30 days.

Rather than referring patients to someone else for their pain medication refill, please provide their pain management care. Many of these patients have been on high doses of opioids for years and are likely physiologically dependent. A slow taper is likely going to be the most successful strategy to wean them off of the opioids rather than abrupt cessation, which will lead to withdrawal. In addition, some patients may have developed a substance use disorder.

Note that some patients may also be on long-term benzodiazepines. The Washington State Agency Medical Director Guideline (AMDG) recommends tapering of high-dose opioids before addressing benzodiazepines use. According to the AMDG, unlike benzodiazepines, opioid withdrawal symptoms are rarely serious.

Consider the following for these patients:

  • Developing a plan to taper the patient off of opioids (in the absence of an obvious substance use disorder or concerns for diversion).
  • Prescribing naloxone for patients on greater than 90 MED or on combination therapy with other CNS depressants.
  • Checking the Prescription Monitoring Program to screen for prescriptions from other providers.
  • For patients with a substance use disorder, referring to an addiction medicine specialist or the Washington Recovery Help Line at 1-866-789-1511, or via the web at http://www.warecoveryhelpline.org/.
  • Referring for case management or care coordination through the patient’s managed care plan.
  • Referring to the patient’s managed care plan’s patient review and coordination program.
Additional information
Providers may have concerns about violating the Washington pain rules by accepting the care of patients on more than 120 MEDs. While consultation with a pain specialist would be ideal in this circumstance, the authors of the pain rules recognized this may not always be an option. As such, the rules outline components of appropriate chronic pain management:

The pain rules also allow for telemedicine consultation. Additional support has been provided to the University of Washington telepain program for patients enrolled in Apple Health. This is a free service that supports primary care providers in the management of patients who are complex or on high-dose opioids. Information about this program can be found at http://depts.washington.edu/anesth/care/pain/telepain/index.shtml.

The pain rules and frequently asked questions about their interpretation can be found at http://www.doh.wa.gov/ForPublichealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement.

Thank you for the services you provide to Apple Health clients.


Please do not reply directly to this message. If you have feedback or questions, please visit the HCA website for contact information.

About Washington State Health Care Authority
HCA oversees the state’s top two health care purchasers — Washington Apple Health (Medicaid) and the Public Employee Benefits Board Program. We work with partners to help ensure Washingtonians have access to better health and better care at a lower cost. For more information, visit www.hca.wa.gov.
 
I would accept no patients from tbis clinic. All risk, no reward. Tbis is for the state to handle, not private practice. When taper turns fatal, you get sued. Precipitated withdrawal with bad outcomes? No thanks.

Should be a state sponsored doc team to clean up this mess. Get them all 6 mo addiction psych care. Then back to pcp.
 
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lobelsteve said:
I would accept no patients from tbis clinic. All risk, no reward. Tbis is for the state to handle, not private practice. When taper turns fatal, you get sued. Precipitated withdrawal with bad outcomes? No thanks.

Should be a state sponsored doc team to clean up this mess. Get them all 6 mo addiction psych care. Then back to pcp.
Click to expand...

A pill mill "rapid response team" could be a way for pain medicine specialty societies to respond to these crises: Just like doctors without borders or other medical mission groups do for other events, a coalition of pain groups could dispatch pain consultants to a site and assist with the orderly transfer of care of patients. This is the third pill mill I've been shut down in my region in the last 5 years--it's good to shut these sites down, but these patients just don't magically disappear--they all scatter and land other places.
 
lobelsteve said:
Shhh. Want ro follow the auction and get the house for cheap.
Click to expand...

These events are also good opportunities to pick up cheap used medical office equipment and supplies for pennies on the dollar--US machines, EDX, par-stock needles, syringes, etc; exam tables, waiting room furniture.
 
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Ducttape said:
inhouse tox labs are only a recent enough development that has not gotten shut down.. yet. just like inhouse pharmacies.

medicaid does not make enough money to justify the time, money, headache, social discord, etc to focus on medicaid.
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Agree completely.

101n made a good point a while ago that if you do a subgroup analysis of the OD deaths involving opioids, that 85% of those patients were on some form of medicaid.

A patient being on Medicaid or medicaid type HMO plans should be an independent risk factor for opioids, and most of the time these patients can't be trusted with standard opioids.

If a person doesn't function well enough intellectually to be able to work full time and provide for their own basic financial needs, how can we believe they can be be trusted with addictive, potentially dangerous medications?
 
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When you have patients nodding off in your waiting rooms, in house narcotic pharmacy, and in house urine tox lab, AND you specifically recruit junkies or soon to be junkies (aka Medicaid patients) to your pain practice, badness will ensue. His entire game plan was to prey upon the junkies or create junkies from scratch and use them to feed his utox lab.
 
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Medicaid closed their panel with a similar pain practice in my state. All the patients ended up in the ER/ED. System flooded with withdrawing patients. No other pain docs in network with medicaid. Thus medicaid reversed their policy and re credentialed the drug dealer. May happen in Seattle as well.
 
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drusso said:
These events are also good opportunities to pick up cheap used medical office equipment and supplies for pennies on the dollar--US machines, EDX, par-stock needles, syringes, etc; exam tables, waiting room furniture.
Click to expand...
Bad karma comes with the cheap furniture... I'd stay away
 
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What frequency of urine tox screen is too frequent?
 
drusso said:
A pill mill "rapid response team" could be a way for pain medicine specialty societies to respond to these crises: Just like doctors without borders or other medical mission groups do for other events, a coalition of pain groups could dispatch pain consultants to a site and assist with the orderly transfer of care of patients. This is the third pill mill I've been shut down in my region in the last 5 years--it's good to shut these sites down, but these patients just don't magically disappear--they all scatter and land other places.
Click to expand...

I actually really like this idea. I would never want to be one of those doctors, but it's a great idea.
 
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drusso said:
According to local television reports, his practice cared for 25,000 patients and 6,000 Medicaid patients. Without a systemic approach or hand-off, what percentage or these patients are at risk for turning to heroin, undergoing questionable surgeries? PCP's are very reluctant to prescribe opioids and WA state is very difficult to get buprenorphine prior-aurthed and paid as they require all patients be seen in community mental health centers.

Provider Alert
July 14, 2016


Effective July 14, 2016, Apple Health (Medicaid) is no longer contracting with Seattle Pain Centers and any prescribers working out of Seattle Pain Centers.
Many of the patients seen in this clinic are on high dose opioids.

The termination of SPC and its associated prescribers applies to Apple Health’s fee-for-service (FFS) program and managed care organizations (MCOs). The agency and its contracted MCOs will attempt to contact affected patients, but may not reach everyone. As a result of the termination, patients may present at your clinics or in emergency departments.

Prescriptions written by providers of SPC who have not had action taken on their licenses will continue to be paid by MCOs and FFS Medicaid for at least 30 days.

Rather than referring patients to someone else for their pain medication refill, please provide their pain management care. Many of these patients have been on high doses of opioids for years and are likely physiologically dependent. A slow taper is likely going to be the most successful strategy to wean them off of the opioids rather than abrupt cessation, which will lead to withdrawal. In addition, some patients may have developed a substance use disorder.

Note that some patients may also be on long-term benzodiazepines. The Washington State Agency Medical Director Guideline (AMDG) recommends tapering of high-dose opioids before addressing benzodiazepines use. According to the AMDG, unlike benzodiazepines, opioid withdrawal symptoms are rarely serious.

Consider the following for these patients:

  • Developing a plan to taper the patient off of opioids (in the absence of an obvious substance use disorder or concerns for diversion).
  • Prescribing naloxone for patients on greater than 90 MED or on combination therapy with other CNS depressants.
  • Checking the Prescription Monitoring Program to screen for prescriptions from other providers.
  • For patients with a substance use disorder, referring to an addiction medicine specialist or the Washington Recovery Help Line at 1-866-789-1511, or via the web at http://www.warecoveryhelpline.org/.
  • Referring for case management or care coordination through the patient’s managed care plan.
  • Referring to the patient’s managed care plan’s patient review and coordination program.
Additional information
Providers may have concerns about violating the Washington pain rules by accepting the care of patients on more than 120 MEDs. While consultation with a pain specialist would be ideal in this circumstance, the authors of the pain rules recognized this may not always be an option. As such, the rules outline components of appropriate chronic pain management:

The pain rules also allow for telemedicine consultation. Additional support has been provided to the University of Washington telepain program for patients enrolled in Apple Health. This is a free service that supports primary care providers in the management of patients who are complex or on high-dose opioids. Information about this program can be found at http://depts.washington.edu/anesth/care/pain/telepain/index.shtml.

The pain rules and frequently asked questions about their interpretation can be found at http://www.doh.wa.gov/ForPublichealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement.

Thank you for the services you provide to Apple Health clients.


Please do not reply directly to this message. If you have feedback or questions, please visit the HCA website for contact information.

About Washington State Health Care Authority
HCA oversees the state’s top two health care purchasers — Washington Apple Health (Medicaid) and the Public Employee Benefits Board Program. We work with partners to help ensure Washingtonians have access to better health and better care at a lower cost. For more information, visit www.hca.wa.gov.
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hey, state of washington: eff off.

i didnt make this mess, and i am not going to provide poor/incorrect care, essentially for free. i am under no obligation to provide opioids to patients who shouldnt have been receiving them in the first place. this really sucks for the ER docs who will ultimately have to deal with this mess

it actually is a big problem for these patients, and i agree that it is good that the clinic got shut down...... but who is going ot pay for the mess to clean it up? ideally, it should be the personal assets of the docs in question, or their malpractice provider.
 
SSdoc33 said:
this really sucks for the ER docs who will ultimately have to deal with this mess
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I'm not in WA, but am EM. I don't have to really "deal" with this. I see these "disenfranchised" patients, but do not prescribe. It's especially grand when the pt tells me I "have to" or "must" write for their meds. I tell them I don't HAVE to do anything. I even leaned a bit o' stuff from you guys here, when I the see the mondo narcs and benzos, and I get to do the public health thing. Fortunately, where I am, it's not the gold or silver medalist.
 
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Apollyon said:
I'm not in WA, but am EM. I don't have to really "deal" with this. I see these "disenfranchised" patients, but do not prescribe. It's especially grand when the pt tells me I "have to" or "must" write for their meds. I tell them I don't HAVE to do anything. I even leaned a bit o' stuff from you guys here, when I the see the mondo narcs and benzos, and I get to do the public health thing. Fortunately, where I am, it's not the gold or silver medalist.
Click to expand...
I've seen a positive shift in ER care in the past few years. Even had an ER doc call me on a Sunday to ask about a patient she didn't feel comfortable with.
 
lobelsteve said:
16 known dead. Systematic failure. Also, kicked off panels for overbilling frequency of UDS for profit. But it gets worse if you read the pdfs.
Click to expand...

I read the PDFs. I also would not condemn him so quickly. We all have patients who are on a combination of benzos and opioids and a slew of psych meds... most of whom we are trying to wean... most of whom have significant challenges getting the mental health care they need. Most of the cases described were polypharmacy in the setting of mental illness. Many of the cases described opioid rotations when patients self-escalated... we all learn about pseudoaddiction and the undertreatment of pain and we know the board questions that are associated with it. We also know that in reality those board questions are a bunch of BS. Many of the patients were also on methadone which is not a bad choice for patients with addiction issues on top of pain issues so clearly he was considering addiction in treatment of these patients.

As far as UDS results go, it was a shame patients were coming back with cocaine... that equals automatic discharge as a patient in my book. As far as concurrent EtOH use, I give them a "two strikes and your out" rule and have a very strict talk... but I do have some leniency. For THC, at least in my state of FL, if it's there, you are out - I consider it illegal behavior... the exception is one patient with a wide open (quite terrible looking) wound from toe amputation who I prescribe for his dressing changes/acute pain and even then its only patch based and topical. I don't know THC legal issues in Seattle.

The PDF's also cite a lack of documenting goals. In my own documentation, I am heavy on goal setting and make patients hand write goals at each visit, screen for balance/falls, worsening of mood, substance use (including EtOH and tobacco), and sleep. However, I have NEVER seen any other private practice document that extensively. I have the same check box templates that others do for warning the risks of opioids. I'm not sure how that did not show up on their EMR for their opioid patients - it's also odd that it only mentions that only one of those patients was not educated on risks of opioids - guilty of not checking the box? I realize the larger issue there is possibly not educating his patients routinely but its only cited in one case.

It does seem he was taking on the most challenging patients (not the good kind of challenging either) and for that, I can understand ordering monthly UDS. For many of my opioid patients, I order monthly UDS if I thought my hands were tied prescribing for the patient and I don't trust the patient - this is usually the case when I received a referral from *(I decided this part of the sentence would be left out given this is public and not in the private forum)* and was told I would be "impugning" the PCP. It sounds like he had many of those patients but then was chastised for ordering "too many." Yes it benefited his business, but he possibly thought since so many were indicated, why not keep a piece of that pie - *cough* everyone else who owns PT/MRI/DME/urine lab *cough*. I don't know which came first, though... the crappy patients or the urines.

Also, let's talk about alternative care (meaning non-opioid care). In FL, there are two hospital based outpatient PT practices that accept medicaid, but for a while they did not and there was NO PT accessible for those patients. On top of that, MRI's and injections were denied since the patients had not had formal PT. Well, then the medicaid patient is supposed to pay $50 out of pocket 2-3 times a week for 6 weeks in order to be eligible for an injection or diagnostic evaluation.

As far as the business practices cited in the document, following the rules is following the rules especially when supervising a PA.

We also never hear anything about a sting, or undercover patients or anything else like that.

Also, if the patient base was 25,000 patients, a large percent of which were medicaid, a large percent of which had mental illness, a large percent of which may have already been on opioids, what is the risk of accidental death in that patient population at baseline?

Now it sounds like the above is justification for the super #$%&-up, superficial, opioid centric, pain care he gave but it is not. It's just a reason why he may not deserve to go to jail. These PDF's didn't prove guilt to me.
 
freddydpt said:
I read the PDFs. I also would not condemn him so quickly. We all have patients who are on a combination of benzos and opioids and a slew of psych meds... most of whom we are trying to wean... most of whom have significant challenges getting the mental health care they need. Most of the cases described were polypharmacy in the setting of mental illness. Many of the cases described opioid rotations when patients self-escalated... we all learn about pseudoaddiction and the undertreatment of pain and we know the board questions that are associated with it. We also know that in reality those board questions are a bunch of BS. Many of the patients were also on methadone which is not a bad choice for patients with addiction issues on top of pain issues so clearly he was considering addiction in treatment of these patients.

As far as UDS results go, it was a shame patients were coming back with cocaine... that equals automatic discharge as a patient in my book. As far as concurrent EtOH use, I give them a "two strikes and your out" rule and have a very strict talk... but I do have some leniency. For THC, at least in my state of FL, if it's there, you are out - I consider it illegal behavior... the exception is one patient with a wide open (quite terrible looking) wound from toe amputation who I prescribe for his dressing changes/acute pain and even then its only patch based and topical. I don't know THC legal issues in Seattle.

The PDF's also cite a lack of documenting goals. In my own documentation, I am heavy on goal setting and make patients hand write goals at each visit, screen for balance/falls, worsening of mood, substance use (including EtOH and tobacco), and sleep. However, I have NEVER seen any other private practice document that extensively. I have the same check box templates that others do for warning the risks of opioids. I'm not sure how that did not show up on their EMR for their opioid patients - it's also odd that it only mentions that only one of those patients was not educated on risks of opioids - guilty of not checking the box? I realize the larger issue there is possibly not educating his patients routinely but its only cited in one case.

It does seem he was taking on the most challenging patients (not the good kind of challenging either) and for that, I can understand ordering monthly UDS. For many of my opioid patients, I order monthly UDS if I thought my hands were tied prescribing for the patient and I don't trust the patient - this is usually the case when I received a referral from *(I decided this part of the sentence would be left out given this is public and not in the private forum)* and was told I would be "impugning" the PCP. It sounds like he had many of those patients but then was chastised for ordering "too many." Yes it benefited his business, but he possibly thought since so many were indicated, why not keep a piece of that pie - *cough* everyone else who owns PT/MRI/DME/urine lab *cough*. I don't know which came first, though... the crappy patients or the urines.

Also, let's talk about alternative care (meaning non-opioid care). In FL, there are two hospital based outpatient PT practices that accept medicaid, but for a while they did not and there was NO PT accessible for those patients. On top of that, MRI's and injections were denied since the patients had not had formal PT. Well, then the medicaid patient is supposed to pay $50 out of pocket 2-3 times a week for 6 weeks in order to be eligible for an injection or diagnostic evaluation.

As far as the business practices cited in the document, following the rules is following the rules especially when supervising a PA.

We also never hear anything about a sting, or undercover patients or anything else like that.

Also, if the patient base was 25,000 patients, a large percent of which were medicaid, a large percent of which had mental illness, a large percent of which may have already been on opioids, what is the risk of accidental death in that patient population at baseline?

Now it sounds like the above is justification for the super #$%&-up, superficial, opioid centric, pain care he gave but it is not. It's just a reason why he may not deserve to go to jail. These PDF's didn't prove guilt to me.
Click to expand...

Then you are just a Radiologist practicing pain and do not understand that patient's prescribed 2 long acting and 2 short acting with A BZD isn't just malpractice, it is manslaughter. Always.
 
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lobelsteve said:
Then you are just a Radiologist practicing pain and do not understand that patient's prescribed 2 long acting and 2 short acting with A BZD isn't just malpractice, it is manslaughter. Always.
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Ouch.

Of course I understand that and I make it a policy to never do that. However, you also know of opioid rotations and changing treatment regimens. It doesn't say those patients were actively prescribed two long acting opioids at the same time... it just showed up in their urines that way and could be during a rotation period or they decided to lie their way into getting more/different opioids. I also know quite a few (not myself) who prescribe two short acting opioids to patients... usually a combination of hydrocodone and tramadol. With a BZD, yes absolutely terrible, no doubt and if there had been any peer review, I'm sure red flags would have gone up, but I can tell you from personal experience that I had a "quality" committee meeting in November of last year where they tried to CONVINCE me that what you are saying was NOT unethical/wrong and the risk was only assumed by the patient. I didn't buy it then and don't buy it now.
 
Well, right now I'm testing every other month. Once a month if I'm concerned about a patient. But it seems like if you don't check every time you write a prescription you might be considered negligent but when you get audited it is "too frequent."

lonelobo said:
If you have to ask, it is probably too frequent.
Click to expand...
 
Stim4me said:
Medicaid closed their panel with a similar pain practice in my state. All the patients ended up in the ER/ED. System flooded with withdrawing patients. No other pain docs in network with medicaid. Thus medicaid reversed their policy and re credentialed the drug dealer.
Click to expand...

Why not shunt to the local, well-to-do hospital system?
 
drusso said:
A pill mill "rapid response team" could be a way for pain medicine specialty societies to respond to these crises: Just like doctors without borders or other medical mission groups do for other events, a coalition of pain groups could dispatch pain consultants to a site and assist with the orderly transfer of care of patients. This is the third pill mill I've been shut down in my region in the last 5 years--it's good to shut these sites down, but these patients just don't magically disappear--they all scatter and land other places.
Click to expand...

Begs the question, what type of stipend would it take for community pain doctors to participate? Is it volunteer work?

Most of the "successful" pain doctors is my area would sooner go out of the country on medical missions than show up at local busted pill-mill sites to clean up the mess.
 
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Agast said:
Well, right now I'm testing every other month. Once a month if I'm concerned about a patient. But it seems like if you don't check every time you write a prescription you might be considered negligent but when you get audited it is "too frequent."
Click to expand...

Who owns the UDS company you use? If you have any profit in it, you are testing too frequently. 4x per year would be a reasonable max. More frequent testing would be an indicator of a patient population that should not be prescribed opiates at all as risk would be too high.
 
I think I'm kind of on the same page as lobelsteve in terms of testing, about 3 per year, but I believe in having random screens in addition to r/o patients that try to cheat. ( there are patients I do test much more: high risk; but not that many)

On a separate note, my state is not librial with Marijuana, but I tend to be more librial on it with patients. I truly feel bad for so many patients that struggle with pain and really want to limit their opioid use. Obviously I'm careful; many patients I have are on a multidisciplinary plan, including on my procedure schedule, PT, mental health therapy, etc. if they are on all the necessary stuff and are upfront with me on the marijuana, then I wouldn't hastily discharge them.
 
Extralong said:
I think I'm kind of on the same page as lobelsteve in terms of testing, about 3 per year, but I believe in having random screens in addition to r/o patients that try to cheat. ( there are patients I do test much more: high risk; but not that many)

On a separate note, my state is not librial with Marijuana, but I tend to be more librial on it with patients. I truly feel bad for so many patients that struggle with pain and really want to limit their opioid use. Obviously I'm careful; many patients I have are on a multidisciplinary plan, including on my procedure schedule, PT, mental health therapy, etc. if they are on all the necessary stuff and are upfront with me on the marijuana, then I wouldn't hastily discharge them.
Click to expand...


aww, thats cute.

MJ is an alternative to opioids? thats news to me.

im guessing here, but you probably havent been in practice all that long.
 
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SSdoc33 said:
aww, thats cute.

MJ is an alternative to opioids? thats news to me.

im guessing here, but you probably havent been in practice all that long.
Click to expand...

Lol. Don't patronize me. I'll cut you. I let them smoke as much as they want only if they watch harold and kumar.

MJ is def not a substitute, but the idea of completely alienating a patient because of MJ is not my style. But I don't feel like getting into that debate right now.

Yes, I'm newer and I don't have a senior citizen card.
 
MJ is an alternative to opioids. I have a few patients who do rather well on it.

However I don't consider MJ an appropriate adjunct to opioids. They don't get both MJ and opioids, just like they can't get benzos and opioids at the same time.

Only one mind altering substance at a time.
 
drusso said:
Actually, the official DOJ agency position from its own Cole memo says, "The DEA/DOJ will say whatever your State says..." unless it involves organized crime, guns, foreign or domestic terrorism, etc. I'm not saying I agree, but chance of actual legal enforcement activity is vanishing small.

https://www.justice.gov/iso/opa/resources/3052013829132756857467.pdf
Click to expand...

Sorry, i wasnt talking patients and recreational use. I was daying the boys in black might come into your office to evaluate your prescription patterns. Co prescribing opiates in known marijuana abusers is not a good idea, as schedule 1 and 2 do not mix. You can argue in court if it came to it and would probably win. Not worth the hassle.
 
lobelsteve said:
Either or but never both. The DEA will have something to say about that.
Click to expand...
I'm not certifying anyone for medical MJ.

exactly what problem will the DEA have if I do an annual lumbar RFA on a patient using MJ for whom I am not prescribing any controlled substances?

I'm not going to deny patients non-scheduled meds, a PT script, psych referral, ESI or RFA, just because they happen to use MJ. I'll still treat them, but other controlled substances are not options for them if they use MJ.
 
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"Complaints against 40 advanced practice registered nurses, four osteopaths, a psychologist and one chemical dependency trainee working at Seattle Pain Center have been sent to the state boards that license those health care workers, he said."

40!!!

The pattern was to hire as many newly graduated noctors and replace them as soon as they wised up.
 
It would suck to go to jail without even getting to be the guy who made the tens of millions...
 
I came across a patient of Frank Li about 1 year ago. Dirty CUREs. I confronted the patient who confessed he was double dipping. Called Li's Beverly Hills office to let him know. Receptionist said "Oh Dr. Li's not here, he comes about twice a month." Confused, I asked why and she said "he flies in from Seattle, we just schedule all his patients on these few days for refills."
 
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