The State Will See You Now by Pat Conrad MD
One can’t make jokes in medicine – or practically anywhere – for fear that the absurd will become reality. The government of my beloved Sunshine State already has a burdensome licensing process, and a Board of Medicine whose members could use 23andMe to trace lineage to the Spanish Inquisition. And now they’ve found a new way up the ass of their physician-servant class: opioid abuse. Amplified by the ridiculous blather about drugs from the White House and AG Sessions, the “OPIOID CRISIS” will now stop the misbehavior of some by punishing the many.
HB 21 has been passed by a bunch of Tallahassee politicians, signed by a governor who made tens of millions as the head of HCA (and left in the swirl of a Medicare/Medicaid fraud settlement), all of whom claim they have consulted doctors to find the best way to curb opioid abuse.
Sure they did. My gut tells me that the politicians told the Florida Medical Association the way it was going to be, and ensured that the doctors consulted were the ones most friendly to government solutions. You can look at the FMA website here to read all the goodies, which involve blowing $50 million in taxpayer money on drug treatment centers, clinic monitoring, and more law enforcement. Another bad waste of good money that will create more parasitic, “vital” state jobs.
The new law reaffirms the definition of acute pain, and caps what a physician may prescribe at a 3-day supply; for an exception, the doc has to write “ACUTE PAIN EXCEPTION”, and document “the lack of alternative treatment options that justify deviation,” and then you can go up to seven days.
For added fun, an Injury Severity Score of 9 or greater requires concurrent prescription of an “emergency opioid antagonist.” So on the Injury Severity Scale, any pain meds prescribed for a femur fracture also means some Narcan. This is tantamount to saying to the post-trauma patient: “I know you really need some pain medication, and I also think there is a significant risk you will abuse it, so hopefully someone will find this injectable or nasal spray on the nightstand if you look a little blue.” That is going to play really, really well in deposition.
The wry joke I heard some months ago was that eventually the politicians would make us check the drug data base on every patient every time. Well it’s no joke as of July 1, at which point I shall be required to check the state drug database every single time I write ANY controlled prescription for any patient 16 and older. The state was already monitoring every controlled script by writer and recipient, information with which it could have done anything to either party; now it is monitoring physician awareness and adherence. There are of course penalties for disobedience: “It should be noted that the DOH is required to issue a non-disciplinary citation to any prescriber or dispenser who fails to consult the database prior to prescribing or dispensing a controlled substance. For each subsequent offense, a practitioner is subject to discipline from their respective board.”
Florida’s war on opioids is of course, a proxy assault on physician autonomy disguised as protecting patients. Sure it may reduce some street availability, which I am confident can be made up by Mexican fentanyl. It might clean some truly sleazy docs off the market, which is fine. But in the grade school logic applied by governments everywhere, those two noisy brats in the back mean no recess for the rest of us. I am one of the most tight-fisted narcotic prescribers I know. Drug seekers literally see my truck in the parking lot and head to another ER. But my state government just told me that, in the interest of protecting innocent patients and dirtball druggies, my quarter century of training and experience counts for shit. I am not to be trusted, and need to enthusiastically embrace prescribed solutions as fast as I can take the mandatory, fee applicable 2-hour opioid awareness CME as a condition for continued licensure. I am the problem, and I will be fixed.
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Part of the problem is also MDs pushing their own agenda.
Emergency Medicine (ACEP) has one of its own board members speak before congress (national and local) touting ALTO (Alternative To Opioids) in ER’s as a solution to all that over prescribing.
They don’t defend that such a small number of opioids are prescribed by ER docs.
They don’t show that they use this method in Teaching hospitals where they have the manpower to do all those US guided blocks.
They don’t say how their “quidelines” for kidney stones using IV lidocaine have only one small poorly done study in the middle east shows it works.
PLEASE, SHOW ME THE EVIDENCE based medicine!
I was a proponent of PDMP when it first came out because it was a major pain to find out if someone was doctor shopping if you suspected it (basically calling every pharmacy in the area to find out if the patient was getting narcotics filled there). I will point out that some people warned us docs that the PDMP would mutate from being used by doctors as a tool for appropriate prescribing practices to a means of the government punishing doctors and patients for APPROPRIATE utilization of narcotics.
This same thing has been going on in Ohio for the last year or so. Essentially, politicians practicing medicine. But, what else is new?
And, by the way, while it’s curbed actual prescriptions, I think the OD rate has gone up. Why? Because Mr. Jones can’t get his Percs, now he goes to the street for some elephant size dose of fentanyl.
My state also starts requiring us to look up patients on the PDMP before every opioid or benzodiazepine prescription as of July 1 this year. I already monitor any new or high risk patients. But now it’s required quarterly for ongoing scripts and for all new ones. . I am also stingy with these medicines already and have had many patients leave when I would not prescribe them. They also started doing background checks on doctors. So now I have to get fingerprinted to renew my medical license. The license I’ve had since 1994.
I heard a brief and bittersweet joke that, of course, vanished when things really became horrific. Perhaps it serves as a test for a society the very bad stuff is still on the way. The joke is funny while times are still not that bad.
Rabbi sits reading the Völkischer Beobachter, apparently enjoying it greatly.
“Rabbi – how can you read that? Don’t you know it’s the Nazi newspaper rag?”
Rabbi says, “You know, every day I worry about the coming threats, about oppression and intimidation of the Jewish people. It gets me down. So I read this rag, and it says, – look here! – ‘Jews are plotting to overthrow Nazism, Jews control international finance, Jews control the British Empire and America, yadda ya. You read that, it cheers you right up!”
There was a time when that was real humor going around the Jewish communities. First funny, and then after a while, not funny at all, and forgotten.
I think of the rabbi’s observation when I read “Doctors are the third leading cause of death, doctors are causing the opiate epidemic, the AMA is manipulating the public mind, doctors drive up healthcare costs.” Johns Hopkins study estimates that more than 250,000 Americans die each year from medical errors. On the CDC’s official list, that would rank just behind heart disease and cancer, which each took about 600,000 lives in 2014, and in front of respiratory disease, which caused about 150,000 deaths. Such power! Wouldn’t you think that everyone who wants wealth and power wishes to be a doctor?
Come right in, and here you are, public. It is all yours.
Does sound like a bunch of BS. I do know of some hospital nurses who took Lortabs and Xanax while working. They got monthly prescriptions and if one ran out before the end of the month, she would borrow from another. Their drug screens were ‘passed’ as long as they had a prescription for their positives. I was appalled that these people were/are taking care of patients. I have had Lortab offered to me twice, once with a kidney stone (I refused it) and after oral surgery (didn’t need anything for pain). The one time in my life that I needed a few Tranxene, I was given Ludiomil (caused ten pound wt. gain/month until I stopped it) and Desyrel which caused two episodes of tachycardia. The second episode, I got out of the bed and went to the couch so that I would die sitting up. Talk about ‘over’ treating. The last Dr I saw, a few years ago, was aware that I was OD’ing on OTC NSAID’S and BC’s for pain and never offered anything else. Guess it’s better to have a patient eat their stomach up with OTC’s than give someone a few Lortabs. Yes, I’m bitter. Apparently I didn’t go the the ‘right’ Doctor. My husband left a dozen Lortabs when he died. I made them last five years. It was sweet relief when I did take one or half of one. I have less hope of getting pain relief now than years ago. That’s saying a lot. Disgusted.
I note that those are ancient drugs, mostly. I’ve never heard of them, other than by history. Your story makes me sad.
Unfortunately our legislators aren’t equipped to practice medicine. The various medical societies, specialty associations and healthcare care corporations who advise government are dominated by physician/administrators who no longer practice real medicine. I often see ER patients with real post-op pain because their surgeons are afraid to prescribe adequate pain control. Our health care “system” is run by people who have little knowledge of what is happening on the front lines of health care.
I’m a family doc and have avoiding prescribing narcotics many times when they probably would have been justified, and yeah some of those probably ended up in the ER. Every time I think about prescribing a narcotic I have to ask myself if the reasoning is rock solid enough that I will not get in trouble for prescribing it. Even then I am taking a chance. It sucks – the patients deserve better and so do we but I don’t see an answer here anytime soon.
I think narcotics prescribing is at a 10-year low but OD’s were up 30% last year. That ought to tell our leaders something but they continue to focus on physicians and prescription meds.