Alabama Pain Management Act Why I Support It

Prescription drug diversion, abuse, and misuse is a serious threat to the health, safety, and welfare of the citizens of the State of Alabama.  It is a problem.  There is no singular medical specialty board which governs pain management.  This makes pain management as a specialty unique from others.   When there is a problem and there is no governing board, the state medical board is the entity to do this. 

 

The big picture problem is 2 fold: the drug seeker / diverter and the pill mill.  These are characteristics of the drug seeker / diverter:

 

n The patient is from out of state.

n The patient requests a specific drug.

n The patient states that an alternative drug does not work.

n The patient states that their previous physician closed their practice.

n Prior treatment records cannot be obtained.

n The patient cannot afford an MRI.

n The patient presents to the appointment with an MRI.

n The patient presents to the appointment with pharmacy profile in hand.

n The patient(s) carpool.

n The patient tests positive for illegal drugs.

n Drug screen reveals no prescribed medications in the patient’s system

n The patient recites textbook symptoms.

n The patient pays in cash only, no insurance.

n The patient calls for early refills.

n The patient’s pain level remains the same.

n The patient is non-compliant with the physician’s treatment plan.

n Prescriptions are routinely lost or stolen.

These are characteristics of the pill mill: 

n The physician has minimal to no training in pain management.

n Cursory or no patient exam given.

n Large volume of patients seen daily (100 +).

n Patients drive long distances, often from other states.

n In many cases patients carpool.

n Clinic owners are not health care providers and have no medical training-they are

typically from out of state (some clinic owners are unscrupulous and have shady

backgrounds).

n Clinic is run on a cash only basis.

n Same prescription “cocktail” for each patient.

n Drugs are dispensed onsite (patient pays for office visit then pays for the drugs).

n Security guards are employed by the clinic.

n Unscrupulous clinic owners convince the physician that the clinic is operating

legally.

This bill lays the groundwork for the Alabama Board of Medical Examiners to regulate chronic pain management with opiate medications.  Currently, any licensed physician can operate as a pain management clinic regardless of intent, training, and ownership.  Unless there is a specific complaint, a rogue pain clinic will go about its business unnoticed for quite some time.  This bill requires anyone operating as a pain clinic to register and meet minimum standards.  This bill also lays the groundwork for what those standards will be.  For example, a pain clinic will require a medical director with specific training in pain management. 

 

I think the bill is a good start.  Most of the meat of this bill will come from the Board where the rules will be established.  I actually welcome this because if this bill is to accomplish its goals, it needs more meat.  For example, requiring the use of the Prescription Drug Monitoring Program (PDMP) by the prescribing provider to make sure the patient is not doctor shopping does work and 43 states have this program in some form already.  Part of this legislation is to make Alabama's PDMP process more user friendly and documentable which is welcomed.  These are things we do already which could be specific rules adopted by the Board:

 

o    Review PDMP (prescription drug monitoring program) report.

o    Require controlled substance agreement to be signed by the patient.

o    Require health care professional face-to-face visits at least every 90 days.

o    Require urine drug testing.  In office screens should be confirmed with toxicology reporting at least 3-4 times per year based on patient risk stratification.

o    Require risk stratification strategies.

o    Require multimodal therapy for chronic nonmalignant pain.  Controlled substances alone are not ideal when treating chronic nonmalignant pain.  We view controlled substances as one of many tools available. Other modalities include physical therapy, bracing, injections, counseling, topical medication, other adjunctive medications. 

o    Make minimum documentation requirements as indicated by the American Pain Society guidelines.

 

One thing I don't want this bill to do, and I don't think it will, is limit doctors who are not pain specialists from prescribing opiates for pain they routinely prescribe.  The problem arises when   the pain becomes chronic and these medications are written on a chronic long term basis.  Therefore, I think it is important to define acute pain and chronic pain and limit this bill to chronic pain so as not to create any undue regulatory burden and hardship on other doctors such as primary care and surgery.  Other states have messed this one up. 

 

I think an area of concern for physicians with regards to this bill and the power granted to the Board is unannounced inspections and suspensions without hearings.  While this does sound quite intrusive, the intent is in the interest of public safety.  Any legitimate pain management clinic has nothing to worry about with this bill.