Catch 22

Recently, A New York Physician by the name of Dr. Stan Li was convicted of two counts of manslauter for prescribing painkillers to patients in New York. The article can be read here – The Doctor was accused of prescribing to addicts and one of the addicts murdered four people in a hold up at a pharmacy. Dr. Li’s case is unusual since unlike most doctors arrested for drug peddling, he was actually an Anesthesiologist / Pain Managment Doctor. Most of the time the phycians arrested are primary care doctors that are trying to make money by do cash patients for pain medications. In Dr. Li’s case, he too charged cash for prescriptions and he would see up to 90 patients a day. The real question is where is the line in the sand. Who determines if the patient is an addict? Does the simple fact that the doctor had a patient or two commit suicide make him guilty of manslaugther? In pain medicine the line is very blurred. There are no real definitions of who requires pain medications and who does not. There is no basis for the amount of medications that are prescribed. I have seen journal articles that have pain medicine guru’s claim that there is no upper limit to the amount of pain medicine they prescibe and they base this on the fact that some people have extreme levels of tolerance. Then I go to the case of one of those guru’s who is the dean of a university pain medicine department who was investigated by the DEA for doing exactly that, prescribing too much. But what is too much? There is no definitions as to what someone should be getting and therem is no way to truly measure pain. How can we the pain management doctors decide what is appropriate without getting into trouble? I regularly see patients that come to me from other doctors and I feel that they are too much medications. I am sure that there are those that feel the same about my patients as well. That is the problem, there is no defined standard for pain control. Pain medicine is a fairly new field. When I finished Residency in the 1990’s there was only a handful of such doctors in the state of Florida and now there are hundreds. Is there really a need or are we just producing addicts? The answer is that there are people in need but we are also producing addicts. The answer is how can we determine who are the addicts. Some pain management departments utilize a multidiscipinary approach with psychiatrists to evaluate the patients on a regular basis. I think that is a great idea but often insurance companies won’t pay for psychological treatments and that makes it hard for patients who often are on fixed incomes. The other issue is finding psychiatrist to evaluate these patients. Why would a psychiatrist want to be “holding the bag” and telling me who is appropriate and who is not for pain medications? Here in our area, we have very few psychiatrists willing to see pain management patients to confirm whether they are appropriate for pain medications or not. That puts the ball back in our court to decide who is appropriate. The other issue that makes the system complicated is that you have one group trying to legalize drugs and another trying to make it more difficult to obtain them. Recently, the DEA decided to make tramadol a Class 4 narcotic. To me that is ridiculous since they are making Marijuana legal whic is ten times more addictive than tramadol. But this now makes a drug which has been around for 25 years more difficlut for us to prescribe. Tramadol became a Class 4 narcotic this month which puts it at the same level as valium. This is the craziness of the system where some groups want to make some drugs legal while others are more restrictive even though they are all about the same in addictive measures. So how does a legitimate pain management doctor take care of his patients? Very carefully! Obviously, people like Dr. Li are the extreme to some extent but it shows the problem with our society. We have a society that wants a pill to cure what ails them. As I have said before, much of this is from the Baby Boomer generation and their thought process that 60 is the new 40 and thus, I should feel good. As people age, they hurt but people of all ages today don’t want to deal with any pain. It is amazing how within 30 years, the amount of narcotic medications prescribed has skyrocketed. I don’t know the answer to the question but there obviously needs to be some guidance from the authorities as to the who, the amount, and the duration of pain medicine treatment. I will continue to attempt to keep patients at the the low end if possible but then what is the low end? Obviously the 500 to 800 pills per month that DR. Li was prescribing was too much but what is the line? Also, if the DEA feels that you are doing questionable practices, shouldn’t they alert you first instead of waiting for you to have patients who overdose? There are a lot of questions that need to be answered. As I have said before, I personally believe in the intrathecal pump for any patient who is utilizing over 60 mg of Morphine eqivalent medication. It puts the control in our hands and really keeps the amount of pain medications prescribed to a low roar. Unfortunately, this is not the standard of care and probably never will be due to the cost of the pump. As for Dr. Li, the big thing that gets these people in trouble is greed. Legitimate doctors don’t take cash only they take insurance and everyone of the doctos that has gone to jail dealt in cash and that makes them look greedy to any jury. In closing, we as pain management doctors must assume that every patient that walks through our doors is a potential drug abuser or trafficer and we have to be vigilant and aggressive with our treatment plans. As I tell my patients, pain medications are not the answer unless nothing else can be done.

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