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.
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
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
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.
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.