Anybody following our blogs is familiar with the fallout that legitimate Florida pain patients are facing as a result of strict new regulations that did not account for the resultant negative impact to patients. This was outlined in detail in Dancing to the Pharmacy Crawl for Opioids and is also highlighted by many patient comments there and at Chronic Opioid Patients Speak Out Against PROP.
Here to review parallel issues in the state of Kentucky is Dr. Debora Tallio, who has nearly 20 years of experience in Physical Medicine and Rehabilitation. Her commentary follows immediately below.
I read with avid interest your piece on the “Pharmacy Crawl”……unfortunately, more and more disenfranchised pain patients in Kentucky are doing a similar “dance” since the passage of Kentucky’s “pill mill bill” (HB1).
It should be obvious that drug addicts, drug dealers, and compliant pain patients are vastly different. Unfortunately, pain patients often get treated like there is no difference.
Drug addicts abuse drugs, and without proper medical treatment, sadly will likely continue to abuse drugs. Addiction is a complex medical problem and is a diagnosis unto itself. Addicts will pursue the easier course…..if they are not given adequate medical treatment to go into recovery, they will continue to seek substances to maintain their addicted state.
Adequate insurance coverage for addiction treatment and psychiatric services is lacking in our country. Unfortunately, many professionals confuse the difference between “physical dependency” (which is a physiological withdrawal response that occurs when chronic opioid therapy that is abruptly discontinued), “opioid tolerance” (more medication needed for the same therapeutic effect due to an adaptive mechanism and mu opioid receptor receptor up-regulation), and addiction (a psychological and physical craving to obtain opioids for a euphoric effect).
Then there are the criminals. Prescription drug abuse drastically increased after 9-11 when our border security increased. Traffickers and dealers are pleased that some criminal cohorts have a medical license to write for pain medications. “Pill Mills” are their gold mines. Opioids are just one example of substances that criminals traffic and sell….limit prescription opioids and other substances will be used and abused. In Kentucky, homemade methamphetamine labs are a serious problem, marijuana crops flourish, and heroin is on the rise. This is outlined nicely in a recent article by Dr. S.B. Leavitt at Pain Pills Wane – Heroin Moves in at paintopics.org.
Let’s look at the positive aspects of the FL and KY “pill mill bills”. Illegitimate pain clinics have closed. Drug dealers no longer have easy access to prescription opioids for diversion. Individuals practicing illegal medicine have lost their medical license. Addicts don’t have an easy stream of opioids to maintain their addicted state so maybe they will decide it is easier to just get help for their addiction. Physicians trying to practice appropriately but without adequate education regarding prescribing and monitoring opioids are now being made to get additional education. GREAT!
Now let us look at the unintended casualties of Florida’s and Kentucky’s “pill mill bills” and excessive regulations. The legitimate pain patients and the legitimate medical providers willing to treat patients with severe intractable pain are being treated as if they are illegitimate. Keeping up with all the “rules” has been onerous for medical providers…a burden that the politicians and certain Medical Boards are willing to minimize or ignore. Many legitimate physicians have refused to prescribe any controlled substances whatsoever because of the time constraints in monitoring and the fear of repercussions from the Board or law enforcement. Legitimate doctors are being “profiled” and investigated (including me) because politicians have appointed a “prescription advisory panel” who targets prescribers, with no correlation to the patient’s medical chart. Although I did nothing wrong, on the paperwork regarding my investigation I am called a “suspect.” Bullying is not allowed in our schools…why is it allowed by lawmakers and peer reviewers? The governor was quoted in a press release last year referencing the advisory panel: “The professionals I’m appointing know the difference between legitimate prescriptions and what constitutes a pattern of abuse.”
Well, if this is the case, why am I being investigated? The definition of “successful” legislation to some appears to be that minimal to no opioids whatsoever will be prescribed in the state of Kentucky for patients with chronic non-malignant pain. What a travesty!
Some politicians seem very happy to have facilitated a divide amongst medical providers….those who think opioids are detrimental and need to be federally controlled verses those who think there is a role for opioids when used appropriately but that more education and monitoring is needed. Like everything in life, there are risks verses benefits. Look at the large numbers of people who are hospitalized or die each year from complications of using anti-inflammatories…. Where is the outrage about this? In fact, anti-inflammatories are prescribed frequently by those who will not prescribe opioids in efforts to control pain.
There are thousands of people killed and disabled every year from motor vehicle accidents, yet we choose to drive our cars because the benefits exceed the risks. No medical provider in their right mind thinks that opioids are benign medications. Our job as medical providers is to evaluate a pain patient, ensure their diagnosis warrants the use of opioids and that opioids are only a part of a comprehensive treatment program, educate patients about the risks, use the dose appropriate to allow restoration of function, and monitor to reduce the risk of abuse and diversion. Given all we know about genetic differences between individuals, is it a surprise that different patients require different doses? Absorption, metabolism, receptor affinity, and excretion drastically vary from patient to patient. Why then the mindset that an arbitrary dose of opioid should help all people? The physician only willing to prescribe very low doses seem either more so concerned about their own quality of life than that of their patients or are too fearful of the medical board or the legal system to prescribe an optimal dose. How easy to only give a few Lortab® or Percocet® a day…..little risk of apnea, drug interactions, opioid-induced hyperalgesia….little risk of slander by peers for being a “drug pusher”….little risk of investigation by a medical board for running a “pill mill”. Wow, I want that kind of practice but that is not what I call true “pain management.”
Some politicians involved with the Florida and Kentucky “pill mill” legislation have not taken the time to look at all the consequences. Yes, illegitimate clinics and doctors have been shut down, but what about the legitimate ones? The legal system has mowed down a forest of animals, killing all the endangered animals just to eliminate a couple of rabid ones. Why would they do this? Politicians are supposed to care about ALL people in their state. Why not pass legislation which shuts down the illegal while protecting the legitimate. It appears we are well on our way to a big government takeover of medicine….quality care for deserving pain patients is being sacrificed.
Pain patients and medical providers who treat pain patients need to speak up now and speak up loudly. In Kentucky, the situation is urgent because the legislature meets in early January to decide about any possible amendments to HB1. Contact your state legislators and Medical Board. In Kentucky where I reside, the sites are www.lrc.ky.gov/Legislators.htm and www.kbml.ky.gov respectively. Let’s try to prevent the “Pharmacy Crawl” from sweeping our state.
BIOSKETCH: Dr. Debora Tallio’s primary clinical interest is treating patients with musculoskeletal pain and chronic pain. She completed a residency in Pediatrics at the Medical College of Georgia and a residency in Physical Medicine and Rehabilitation at the University of Michigan Medical Center. She is a member of several pain societies and is on the board of the Catholic Medical Association Guild in Lexington. Dr. Tallio is currently treating patients in Lexington and Irvine Kentucky.