Between Christmas and New Year’s Day not much traditionally happens in most businesses. Everyone just “chills out” and makes resolutions for the coming year. Many use this time to reflect on what has happened in the year about to end.
2008 has been a good year for the ASPE. We have held another Pain Educators Forum (PEF), launched our Certified Pain Educators (CPE) examination, have super-charged our members of the Board of Directors to think strategically about the organization, and have started planning our 2009 activities.
While not meaning for this entry to be a “State of the Union” address, it is nice to say that the ASPE is strong, has continued to expand its mission, will continue to be a driving force in pain education, and that the best is yet to come. While the overall economy is nothing to write home about, the ASPE is something to be proud about, and a place to be for those committed to improving pain management services through education.
Already dozens of people have started the application process to take the CPE exam, a dozen have been qualified, and few have actually taken the exam. This opportunity to be in the first group of candidates runs through 1/31/09. There will then be a “black out” for a couple of months and in the late spring another opportunity will be created. The first group taking the exam before 1/31 will determine the “cut score” (passing point) for future test takers. Future test takers will immediately know if they passed the CPE exam after the “cut score” is set.
As one of those who took the CPE exam I found it very different from the paper and pencil test of my youth. Done entirely online, it was well constructed for online presentation. There were several ways to select the desired answer, a second window to open when necessary to view the case studies, and a clear tutorial to get me started. While the test center staff knew nothing about the exam per se, except how to set me up to take the exam, there was nothing for them to do other than watch me take the test. For those not familiar with computer testing it was no more challenging than reading your e-mail. Everything was on the screen.
I am excited to say that in 2009 Ms. Liz Stueck and I will be beefing up the services of the ASPE under the direction of our Board of Directors. Our Board continues to grow in size and to acquire skills and talents from each new member. We have members from business, law, medicine, pharmacy, and social work, and have an invitation out for nursing. We want the Board of Directors to reflect the membership.
Like other organizations the ASPE needs committed members willing to take on projects. In most groups there are a few people who do all of the work. The ASPE’s CPE exam development group has been comprised of over 25 people during the past 3 years. There will be more needs in 2009 and beyond. Are you ready to be more active in the ASPE? Are you looking for something to do to advance the field of pain education? This is your chance! Please let me know what you’d like to do and I will help you realize your dreams.
I wish all of you a very happy New Year 2009. I hope that the hard economic times won’t dampen your spirits to move pain education forward. Together we make light work of the heavy lifting needed to be a professional discipline.
A few months ago I agreed to be an expert medical witness for a physician charged by the US government with bad faith prescribing, bad faith billing, bad faith living, and several other bad things. I spent this past weekend I with 3 attorneys (Eugene, Lawrence, and Kevin), their information management specialist, another physician, and the president of a national pain advocacy group pouring over charts. My desire was to be able to find things in the medical records that differentiated what was done from the “services” commonly attributed to “script mills.”
For the purposes of this entry, a “script mill” is a medical practice that is solely intended to deliver desired medications to those wishing to receive them without any legitimate basis, almost always operating as a “cash only” practice, and frequently having odd structure. This example might help make this point: a “clinic” operates from 6 pm to 4 am 4-5 nights per week in a rundown area, with a single physician using 1 or 2 extenders, seeing 160 patients (20 per hour), accepting only cash, charging $250 per individual prescription for those waiting in the line that stretches more than a city block or $350 per prescription for those waiting in the short line, protected by two armed guards, where the “exam rooms” are equipped with folding card tables and chairs, without any access to labs, imaging, or other diagnostic services. A variation on that theme involves the occurrence of tail-gate parties in the parking lot, presence of uniformed police officers directing traffic in and out of the facility due to the high volume of traffic, being located very near a state boarder and in a rural location. These examples are not “all inclusive” but should give you an idea about “script mills.”
Legitimate medical practice involves seeing patients (not customers), performing historical interviews to determine the problem being addressed, doing a problem specific physical examination, ordering appropriate laboratory/imaging/electrodiagnostic studies to establish the most accurate diagnosis, prescribing medication (if indicated) within a framework (providing efficacy and safety), seeing patients on a continuing basis, monitoring improvement in pain intensity, ability to engage in activities of daily living, and noting overall compliance with the mutually agreed upon plan of care. So, if a patient presents with a pain complaint, has physical findings supporting the generation of pain from the area being described as painful, receives medication within the structure of an opioid agreement, is seen regularly, has medications adjusted and side effect addressed, and reports improvement in well-being, isn’t that the legitimate practice of medicine? Does that sound reasonable to you?
Bluntly, the “dealer” doesn’t want to work patients up for their complaints, isn’t going to make referrals to specialists, won’t order diagnostic tests, doesn’t manage any problems other than pain, and will only continue to prescribe medication without any diagnostic testing, consultations, use of ancillary services. The responsible prescriber wants to understand the context of the pain process, what makes it better or worse, what response there has been to prior treatment, establish an ongoing therapeutic relationship with the patients, and help those who are suffering.
Today, the reality of family practice meets the medicolegal scrutiny of the “federal” agent. In busy family practices seeing 40-60 patients per day is normal. Most encounters are short, problem-focused, and represent “acute” more than “chronic” management, except for problems such as diabetes, high blood pressure, arthritis, etc. In comes the “chronic pain patient” (actually a person living with chronic pain) who has anxiety and depression, weight gain, physical conditioning, and pain out of proportion to pathology. The usually FP response is to treat the patient for what bothers them, try to get a handle on whatever is going on, and follow the patient until better or refer out to a specialist. The “federal agent” has the book of “rules” that change periodically, and many of the rules are subject to interpretation, and the “federal agent” is supported by the “pain specialist” who wants to be a police officer. Law book and pain society “guidelines” that have very poor evidence and best, and are frequently just the consensus opinions of a few become “written in stone” truths to be enforced.
How did I spend last weekend? Trying to interpret charges in an indictment and find evidence in the medical records that would refute the charges. Often this came down to deciphering illegible handwriting (not so easy even for physicians to do), thumbing through hundreds of pages of material to find a referral letter, and then making secondary interpretations of the findings in autopsy reports.
Distilling this blog entry down to be something useful for every physician, please stop scribbling and start writing in block print letters and/or invest in dictation software or a real transcriptionist. What isn’t in the charts or cannot be read won’t help you, and it sure makes the reviewer’s job impossible. If you are going to use opioid risk screening tools then please know what the information generated means and respond to it in real time. If you order tests, like drug screens, and they don’t come up as expected please explain in the record what the variation means, and what you plan to do about it.
Much of the trouble the physician whose charts I reviewed stems from having brief, illegible notes, with a pattern of prescribing that was different from others in the community. As I read through the charts I could see genuine medical practice, a pattern of working with patients not generally seen in procedurally based pain programs, and concern about their well-being. Assuming the jury understands my testimony in a couple of months I hope to report that innocence was established. If not, the physician will go to prison for a very long time.
The criminalization of medical practice is a dangerous and slippery slope. It the standard for modern medical practice becomes the “Attila the Hun method” (eg, kill an occasional Hun to keep the others in line) there will soon be no one left in American willing to prescribe opioids for pain. That will be a far worse outcome than the few thousand deaths annually attributed to opioids in the US, won’t it? Can you imaging living without the option of opioid therapy? Would you want to do so?
What do you think? Leave me a comment. Thanks.
My son and I just spent 3 days driving between Detroit, MD and Las Vegas, NV. Elliot had taken the buyout from Chrysler and I helped him drive his Toyota pick-up truck filled with possessions back to our home in Las Vegas. His departure from Chrysler happened very quickly. One day he was sourcing wheels and tires, and a few days later he was applying for a buyout in 3 weeks. He packed up his few Chrysler possessions, and left the building in Auburn Hills for the last time on the afternoon of 11/26.
By 12/4 he had closed down his house, loaded his truck and a trailer, and then picked me up in a snow storm at the Detriot ariport to make a 2200 mile drive with him. The ultimate bonding experience: a 3-day cross country drive with my now "bought out" son, and the 2009 edition of What Color is My Paracheutte to help him find himself. We read several chapters together each day as we took in the sites around us: the largest cross in TX, the endless vistas of Oklahoma, Texas and New Mexico. We listened to a lot of music from his iPod, mostly ska and punk.
What we saw as we crossed America was a mix of vibrant growth and misery. In the outskirts of Indianapolis, St. Louis, Oklahoma City and many other places there was ongoing new construction, but within close proximity there were single wide trailer homes. Downtowns in many cities and towns were virtually abandoned. Only the parking lots of Wal-Mart Supercenters were consistenly filled.
Despite the start of the trip in snow, within one night we hit brilliant bright blue sky, clear roads, and plenty to talk about for the 3 day dash. How hard it was for me to talk adult to adult with my soon to be 24 year old son. He was different than than the young man I had helped move to MI early last year. So much had happened to him during his 18 months in MI working for Chrysler.
Now he's trying to figure out what to do next with his life. Considerations range between specializing a MBA into China studies, or getting into industrial engineering, to looking for work with a company specializing in the development of alternative energy.
For me, it was a chance to visit cities where I had given pain lectures 5, 8, 12 years ago. To see smaller towns still stuck in time, but in many cases continuing to fade away. Even I-40 had changed. Having been back and forth on it since 1978 it seemed very modern in some places, and then as primitive and rural as ever. A highway built in the 1950s, but working in the 21st century.
The message of the trip for me was about the greatness of the United States through good times and bad. I saw the ability of people to apply themselves to work hard to realize their goals. I saw the blight of obesity, especially through the Midwest, and its inevitable toll on our country. I heard older Americans complain about pain, hardship, with a belief that things would be OK. Despite all of this, people smiled when I pumped gas, walked my son's dog, or just waited for my food order.
My son and I resolved none of the world's problems. We had a wonderful and exhausting time together. I am so glad I had this time with him. It was a gift.
The New York Times, Washington Post, and USA Today all had articles today (12/3) about the extensive hours worked by physicians in training (residents and fellows). You may recall that back in the “good old days” physicians in training worked more than 100 hours per week (my personal maximum was 110 in 1980 during my internship). That led to a high profile death in the mid-1980s and a limit instituted of “only” 80 hours per week, and no more than 30 consecutive hours (my person record was 40 hours during my internship).
The reason used to justify the need for physicians in training to spend so many hours on duty is to see the continuity of care during the early presentation of sick people. Supposedly, assuming care of someone at the time of initial presentation and following them for the first day or two means that you learn more about the natural progression of the condition. I think that in the era before CTs, MRIs, extensive laboratory testing this was a reality, and why pharmacies and many physicians had “sick rooms” where patients could stay until what was wrong was determined.
The argument against 80 hour work weeks and 30 hour work days is that very few people can remain that sharp and function. Once in a while, during an emergency, most people can hold together for 24 hours, but very few people can do this 2-3 times per week, 52 weeks per year. Most fire fighters do not stay awake for their 24-hour shifts. Long-haul truckers are not permitted to drive more than 10 hours per day. Pilots max out after 10-12 hours of flying in 24 hours and only fly 11-12 days per month. All of these professions have mandatory rest/sleep periods because it is deemed unsafe (and therefore dangerous for the public) not to do so. When it comes to caring for sick people common sense and safety go out the window. Who cares how tired the physician is, just keep seeing more patients and making bad decisions.
Hospitals have a stake in this argument. They’d have to pay many more people to work if they could extract 80 hours of work per physician in training. Most practicing US physicians work about 60 hours per week throughout their careers. If residents learned to live their lives sanely when in training would they continue to put in 60 hour work weeks after completing their training?
I have believed that residents and fellows should never work more than 12 hours with perhaps 13-hour days created to permit shift changes. Nurses sanely have three 8-hour shifts or two 12-hour shifts, provide the majority of medical care that most people receive, and do still make medical errors. If continuity can be maintained by nurses, wouldn’t this also work for physicians? As we move from one primary care provider being all things for all people, to outpatient internists, family physicians, and nurse practitioners dealing with the day-to-day issues and leaving serious problems to hospitalists, can’t we create a sane system of medical education?
There will be emergencies and crises requiring limited deviation from established work routines, but I think we have come far enough in healthcare education to actually teach our physicians in training how to care for sick and injured people without consuming themselves in the process. It is time to stop the madness, and agree that 5-6 12-hour shifts per week are an acceptable way to train healthcare professionals. What we need to teach everyone is how to effectively communicate. The current system leaves the next man or woman on duty ill prepared to care for the people assigned. Let’s fix the obvious problem, and the other problems will likely sort themselves out.
What do you think about this?
Happy Thanksgiving! This is the time of year when we eat turkey, over eat special foods, watch football on TV, celebrate all that is good in our lives, and renew our love of family and friends. While the original connection with the early settlers of this country has been lost by most, Thanksgiving has become the official start of the “holiday season.” For the next few weeks we will attend holiday parties, spend more time with friends and family, spend money in stores, and likely even put on a food extra pounds.
I give thanks this year that over the past year the ASPE has evolved and passed a milestone. The certification examination for pain educators has moved from being an interesting idea with a job analysis to having questions written, a test form developed, and applications coming in. Next Monday, December 1st, members will begin taking the examination. With testing and certification, ASPE members become part of a new profession: Certified Pain Educators.
I give thanks (and continue to hope) that within a few years there will be a Certified Pain Educator in every healthcare facility, managed care organization, group practice, and where ever people with pain seek help. This may be my “pipe dream,” but I can imagine how different the lives of tens of millions of people would be if their pain was meaningfully controlled. Terms like “pain management” and “pain control” suggest that pain is not entirely relieved, but adequately addressed. I want to believe that in the future we will do more than just manage and control pain, but effect “cures.” Until then, what if primary care providers, and those first responding to injured people, could relieve pain early in the process? Would that derail the inevitable decline into chronic pain that so many Americans endure? Would early intervention spare millions the long term suffering now experienced by our husbands and wives, mothers and fathers, brothers and sisters, sons and daughters, and friends?
We know how bad things are with regard to pain in America, acute and chronic. Survey after survey done with different populations remind us how many people now living with chronic pain are at best coping, and at worst are just miserable. Many of them are disabled, barely managing to get by from day-to-day, dependent upon medications to make the most basic activities of daily living possible, and not able to realize their potential. Suppose that early recognition, treatment adherence and optimization, and effective management of pain happened sooner rather later. Would that be a worthy goal in itself, or because of the cost savings that would result?
As always, there are many unresolved questions. This is the time for thanks giving. We should be thankful for the better understanding we now have about the generation of pain. Thankful for the many FDA-approved medications and devices with mechanisms of action linked to the causes for pain. Thankful for scientists and clinicians who are unraveling the pain puzzle. Thankful for the legislation bringing more pain services to those on active military duty and those who have served our nation. Thankful for the commitment and dedication of people not in pain making lives better for those who are in pain. What a beautiful world!
Happy Thanksgiving and best wishes for the upcoming holidays. For those who will be taking the CPE examination in the coming months, best wishes to you on your personal transformation from healthcare provider to pain educator.
Last night it was reported in the 11/19 issue of JAMA that ginkgo does not delay the progression of Alzheimer’s dementia (AD). The so called “elixir of mental acuity”, ginkgo biloba was evaluated in a large study described as a “randomized, double-blind, placebo-controlled clinical trial conducted in 5 academic medical centers in the United States between 2000 and 2008 with a median follow-up of 6.1 years. 3069 community volunteers aged 75 years or older with normal cognition (n = 2587) or mild cognitive impairment [MCI] (n = 482) at study entry were assessed every 6 months for incident dementia while taking twice-daily doses of 120-mg extract of G bilboa (n = 1545) or placebo (n = 1524).”
The results published in the JAMA article were: “523 individuals developed dementia (246 receiving placebo and 277 receiving G bilboa) with 92% of the dementia cases classified as possible or probable AD, or AD with evidence of vascular disease of the brain. Rates of dropout and loss to follow-up were low (6.3%), and the adverse effect profiles were similar for both groups. The overall dementia rate was 3.3 per 100 person-years in participants assigned to G bilboa and 2.9 per 100 person-years in the placebo group. The hazard ratio (HR) for G bilboa compared with placebo for all-cause dementia was 1.12 (95% confidence interval [CI], 0.94-1.33; P = .21) and for AD, 1.16 (95% CI, 0.97-1.39; P = .11). G bilboa also had no effect on the rate of progression to dementia in participants with MCI (HR, 1.13; 95% CI, 0.85-1.50; P = .39).” The conclusion from the study was that “G. biloba at 120 mg twice a day was not effective in reducing either the overall incidence rate of dementia or AD incidence in elderly individuals with normal cognition or those with MCI.”
On the strength of the data, there does not appear to be any reason to take ginkgo. What is important to note is that the population studied was 75 years or older, not middle-age men and women. Could there be benefit for taking supplements earlier? If the goal is prevention, then how early in life should supplements like ginkgo be started? No one has yet to resolve these questions.
I am one of the aging baby boomers. I have said for many years that baby boomers unlike their depression era parents would not grow old gracefully. I am not, that’s for sure. I predict that baby boomers will attempt to remain active for as long as possible, engaging in athletics that are often termed extreme (eg, running 10 marathon races in one year to celebrate turning 50 years old, summiting every major mountain in North America, making 100 free-falls, or learning technical scuba diving and going to the Chuuk Lagoon to dive on the decaying Japanese wrecks deeper than 130 feet, etc). Older Americans are now doing things that previous generations never considered, likely because they were struggling to get along (some might argue because they had better things to do).
In parallel to the development of the field of modern pain management there has also been a keen interest in anti-aging medicine. To some extent, the two fields may be overlapped, and in doing the things done to retard the aging process, there may be improvements seen in pain. The reverse may also be true, and for those working in comprehensive pain management programs it is common to see significant overall health improvements coincident to cessation of smoking, appropriate medication use, practice of behavioral methods, better sleep, diet, and exercise.
Radical as it might seem, perhaps the answer for many current medical problems might be found in the comprehensive pain management programs of the 1980s and 90s. I doubt we will find a single pill to swallow to fix what ails us. More likely, we will find just what our pain researchers have frequently told us: it is not one thing, but all of it done together that makes the real difference.
I wish there was a single pill that kept everything in perfect homeostasis. I hope a gifted scientist will one day discover that elixir. Until then, like millions of other Americans I will watch what I eat, keep my weight in check, limit my intake of alcohol and caffeine, never smoke or use tobacco products, get regular aerobic and resistance exercise, obtain 7 hours of sleep/day, and all of the other things that my grandmother told me to do 40 years ago when I was a teenager. Her advice then was to have a glass of wine every night. Some things really don’t change!
REMS? What's a REMS you may be asking. It is a Risk Evaluation and Mitigation Strategy. It is required for all controlled substances now coming to the US market. The folks at the FDA are not going to let anything come on to the US market that can be abused, misused, diverted, or taken by someone for any purpose other than the legitimate medical purpose for which the medication was prescribed. That sounds like a wonderful goal even if it is completely naive.
The problem seems to be that the folks at the FDA know what they want as the end product (no abuse, misuse, or diversion), but they have no clear idea how to get there. In fact, at last week's FDA hearings for the new medication Remoxy, when specifically asked by an advisory board member for the exact standard being sought the FDA representative simply said, "We were hoping you would tell us." It reminded my of the Supreme Court rule saying that you didn't need a definition of pornography because you knew it when you saw it.
That got me thinking again, always a dangerous thing when I have too much free time. I tried to imagine what would be an iron clad REMS that would make the FDA, DEA, DOJ, FBI, and the other 3 letter state and federal groups happy? How far should standards be raised to absolutely (100% of the time) get needed medications only to patients for whom they were intended without any possibility for abuse, misuse, or diversion. How draconian can we make the system and still help those in pain despite whatever inconveniences they might have to tolerate. While not completely fleshed out, I came up with these 10 preliminary steps:
1. Opioid medicine shall be made from Kevlar, titanium, activated charcoal, and bicarbonate so they cannot be crushed, extracted in acid or alcohol, cut, chewed, or otherwise physically or chemically altered;
2. Medications shall be prescribed only by board certified pain specialists with 25 hours of DEA approved Schedule II specific prescribing CME, ASAM (or equivalent) addiction certification, and Police Officer Safety Training (POST);
3. Medications shall only given to patients with certified terminal illnesses from which they will die within the next 90 days (who have been fingerprinted and cleared of all known criminal offenses, submitting DNA swabs, along with hair, urine, and saliva samples for toxicology);
4. Medications shall be delivered to patients one pill at a time by licensed clinical pharmacists from Brinks armored trucks coming to their homes every day at the same time (only once daily, controlled-release medications will be permitted);
5. Medications shall be administered directly into patients open mouths from the gloved hand of his Holiness, the Pope or his representative if more than a few people in the US require controlled substances;
6. Pill administration shall be witnessed by DEA field agents dressed in body armor and wearing blue windbreakers saying DEA;
7. All medication administrations and one-hour outcomes will be documented in the electronic medical record kept jointly by the DEA, State Board of Pharmacy, State Medical Board, State Nursing Board, and the Vatican by a RN within 1 hour of each dosing event;
8. All bodily excretions produced by patients shall be saved and sent for chemical analysis to determine the individual pharmacodynamic and pharmacokinetic variables, presence of prescribed medications, presence of illicit medications, and metabolites of all of these;
9. Anyone living with patients receiving controlled substances shall also submit their bodily excretions for similar analysis;
10. Everyone involved in the aforementioned process shall be immediately arrested, tied, and if found guilty executed for any breech in protocol, unexplainable test results, etc.
I challenge you to propose a tighter system. Like Mission Impossible challenges to Ethan Hunt, what are your ideas to create a foolproof system that prevents any abuse, misuse, or diversion, and immediately makes such acts known to the authorities so that instant justice can be delivered? Remember, people abusing medications cannot have any untoward health events as a consequence of their illicit or inappropriate drug use (it's not sporting to hurt them). Think about the concept of "catch and release" as your guide. You may want to stun abusers in some way so law enforcement can more easily arrest them, but you cannot harm them.