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Chronic Neuroimmune Diseases
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Last updated January 1, 2014

If your doctor's not breaking the law, why is he so paranoid about prescribing the appropriate pain medications for you?

© 1998 Melissa Kaplan

Interesting question, eh? I have been having a problem assimilating two very disparate inputs: people whose doctors refuse to give them necessary pain meds, even when they see that the medications work, because "the feds will breathe down my neck" or "they don't work" or "they will addict you" on the one hand, and the feds - in the form of legislation already on the books and as discussed by a Department of Justice drug enforcement agent - saying "prescribe what is necessary to treat the patient."

Granted, I'm having trouble assimilating most things nowadays, like when I wake up and struggle for a half hour or so to remember my name and where I am (and I'm not even on drugs!). But this clashing discordant tune played by patients and doctors was getting to be too much. So I started digging.

A trip to the library yielded a copy of the California Intractable Pain Law (B&P 2241.5). A hand-out from the Interstitial Cystitis Pain Conference last September revealed a copy of the hard-to-find California Pain Patient's Bill of Rights. It also provided some good quotes, which you will find salted throughout this and future newsletters, as well as a talk by Dale Ferranto, Special Agent in Charge, California Department of Justice.


Underfunded, Understaffed and Spread Way Too Thin
This about sums up why the DOJ and DEA have not been able to look long and hard at all 250,000 Schedule II prescribers licensed in California nor the 5,000 pharmacies licensed to fill these scripts. The triplicate system, which was put into effect decades ago, is cumbersome, inefficient, and simply not working. Not only do the prescribers have to keep a paper copy on file for three years, so do the pharmacies filling these scripts (and having been behind the counter at a couple of them, I can tell you there simply isn't a lot of file space for anything but stock); the pharmacy sends the third copy to Sacramento. There the information on the form is supposed to be entered into a system, but they are so far behind that it effectively isn't being done, certainly not on anything resembling a timely basis. If an agent should want to review the scripts written by a particular physician, or for a particular patient, or filled at a specific pharmacy, weeks of manual searching through all those little pieces of paper must be done. Hardly an effective system. And hardly one that an agency also responsible for shutting down crack cocaine houses and clandestine methamphetamine labs, and trying not to get themselves killed when going after drug dealers armed with automatic weapons and explosives, is gonna have a lot of time to deal with. In fact, there are only one or two people who have time on any regular basis to do such monitoring and observation.

What follows is a summary of Special Agent Ferranto's talk:

- There is a real problem out there with health care professionals, whether it is real or perceived to them, thinking the regulatory enforcement authorities of the government, both state and federal, are always looking down from above to meddle and interfere with the practice of medicine, particularly when it comes to the prescribing and distribution of controlled substances.

- The real facts of the matter are that there aren't enough of us out there to monitor the activities and behaviors of the 100,000 physicians in California, for instance, nor do we have any desire to do so.

- What we are most interested in as an enforcement authority are the dishonest doctors or prescribers. There are a small percentage of prescribers who are dishonest, selling their scripts to make a little extra income. Other doctors are duped by patients who don't need the medication or need it to maintain their addiction. Another category of concern are those physicians who are themselves addicted to controlled substances because that interferes with their ability to practice medicine. Finally, we are concerned with those doctors who a danger to their patients because they haven't kept up with the required continued education. For some reason, they can be scammed easier or they've just fallen into the habit of prescribing just for the sake of saying that they are practicing medicine. But our main concentration is on those prescribers who are dishonest, less than 1% of all prescribing physicians in the state. It is enough to cause a problem in California, and it's enough for us to be worried and continue a monitoring system, particularly for Schedule II drugs, but it's certainly nothing for the other 99.9% prescribers to be afraid of.

- In fact, there is an easy way to relieve some of that paranoia. All we have ever said is that, when we check things, we check records. We check to see that a good work-up was done, a diagnosis was attempted, a good physical was conducted, and that the physician acted within reasonable direction in using controlled substances to treat the condition diagnosed.

- With that type of documentation, most of those prescribers should be relieved of any fear of a criminal or administrative action from governmental authorities. So, it is recordkeeping and a good work-up that keeps everybody satisfied.. If your doctor is not prescribing you the medication that you need and you feel that it's not because you don't need it but because of the fear of the physician to being watched over by the government, of being regulated by the DOJ and DEA, then that is a problem that needs to be addressed with that prescriber.


So, where does that leave us?
Doctors have to buy the triplicate forms and are allowed only X amount a month. If they need more, they can apply to the state medical board which, from what S.A. Ferranto has seen, never denies legitimate requests (like, from doctors treating cancer and pain patients). Perhaps there'd be less work for these doctors if they would prescribe more than a couple of days or a week's worth of medication at a time - that way, they wouldn't always be "bothered" by those pesky patients needing refills of drugs needed for their chronic conditions, and they wouldn't run out of their controlled forms so fast.

But something else comes to mind when I was listening to the talk and reading my notes... Could it be that the doctors who say they are worried about the "feds" breathing down their necks either have had the feds breathing down their necks for some reason (like inadequate documentation,) or are afraid that if the feds do come a-breathing down their necks they will find that they have been, uhm, less than scrupulous about interviewing their patients, ordering tests and copies of prior physicians medical records, and documenting same in their own files?

Could it be that the doctors who continue insist, despite the research to the contrary, that narcotics cause addiction in chronic intractable pain patients, that opioids aren't effective in treating chronic severe and unremitting pain, haven't been keeping up with their continuing education.

Hmmmm...on the one hand, a sloppy doctor whose lack of accurate record keeping could ultimately adversely affect your health and quality of life, or a doctor who falls into that .1% of "dishonest prescribers, as DOJ agent Ferranto so nicely puts it. Or, could it be that, like the sloppy doctor, the lack of continuing education could be a danger to you?

Okay, so chronic, severe, unbearable pain won't actually kill you. But should suicide (or street heroin, as many have done) be forced on patients as the only truly effective method of pain management when their doctor refuses to prescribe because they are behind on their paper work, behind on their state-mandated continuing education, or, heaven forbid, already at risk because they're in that .1% category that the feds do look at when they have the time and manpower?




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