Demystifying the Facts and Debunking the Myths
By David W. Gale, M.D.
“Houston, we have a problem …”
Lets not use this space to go into the details of the problems and controversies surrounding prescribing narcotic/opioid medications. Instead, lets get the facts straight. I hear stories from patients who have been referred to me all the time that causes me to shake my head.
Even some of the things I hear from fellow specialists are misleading. “The new laws do not allow me to prescribe pain medications anymore.” False. My license won’t allow me to prescribe any narcotics.” False. “Only pain specialists can prescribe this stuff now.” False. Etc, etc, etc.
I will attempt to demystify a few of these items and show how these new laws and rules are actually making things safer for you as a doctor and your ability to treat your patients.
The Georgia Pain Management Clinic Act (HB 178), aka the “Pill Mill Bill,” was signed into law in May 2013.
This bill was passed to keep out the bad guys. It was NOT passed to put fear into Georgia physicians who are simply trying to take care of their patients. After Florida had a statewide crackdown of “pill mills” in 2010 and 2011, the players and bad actors moved north. We all saw the signs on the highways and exit ramps advertising for pain care, “no insurance or referral required!!”
While most of this business involved patients from outside Georgia driving here just to get an easy prescription for high-dose oxycodone (up to 240mg per day!!), many unsuspecting Georgians thought these outfits were real doctors. Unfortunately, they were real doctors, with a Georgia license no less. But the owners of these practices were not, and the physicians working there had violated every oath ever taken. The only motive was profiting from selling prescriptions.
Because Georgia passed the “Pill Mill Bill,” their view now is from behind bars. For the most part, the law has worked as intended. All medical practices where more than 50 percent of the patient population receives Schedule II or III controlled substances to treat chronic pain must now be licensed by the Georgia Composite Medical Board (GCMB). This law is simple, and it makes sense. The law allows the medical board to perform background checks on the physicians and to make sure each office is owned by a physician with a Georgia medical license. It’s that simple. It keeps the Bad Guys out.
In truth, very few medical practices have more than 50 percent of their entire patient population on daily doses of opioids for the treatment of chronic pain (with the exception of oncologists who are specifically excluded), so this law probably does not apply to you. So you may continue to treat Mrs. Pratt who has horrible knees and just needs three or four hydrocodone doses per day to keep her going but her cardiologist won’t clear her for surgery. You may still treat Mr. Johnson who has had three back surgeries and is well managed with low-dose OxyContin. However, if you DO decide to continue to treat Ms. Pratt and Mr. Johnson, the following section does apply to you.
Medical Board Pain Management Rule. Initiated Feb 2012, updated Nov 2013.
Our legislators and state medical societies worked closely with the Georgia Composite Medical Board (GCMB) to pass sensible rules and guidelines for the treatment of pain. The goal is to allow pain management to continue to take place in Georgia for our citizens in need of such care and to allow competent physicians to provide such care to their patients. That is what we went to medical school for last I checked!
Here is a summary of the GCMB Rule 360-3-06, Pain Management. A quick check of the GCMB website will announce any future updates. (This actually is a VERY informative website for many things besides renewing your medical license).
- The Pain Rule only applies to those patients needing essentially daily opioid medications for more than90 days to treat chronic pain. These guidelines DO NOT apply to in-patients, terminal patients, hospice patients, those in nursing homes or a patient who just needs intermittent medications (as opposed to daily) for a non-terminal condition. Attention all Surgeons, these rules DO NOT apply to any pain problems being treated by you during any peri-operative period (such period may last 2-6 months depending on the actual condition being treated), which allows surgical care to be unhindered.
- Need an H&P. This is what we do every day. We need to make an attempt to get records from previous physicians and any imaging studies. We need to actually perform a physical exam, which the “pill mill” doctors rarely did.
- When prescribing Schedule II and III controlled substances for chronic pain, noting the above exceptions, these patients need to be seen at least once every 3 months. The patient must have also signed a treatment (opioid) agreement or “pain contract”
- When prescribing Schedule II and III controlled substances Â for chronic pain, these patients need to be monitored using body fluids (typically urine drug testing or UDT) to make sure the medications you are prescribing are indeed in the patient’s system, and other non-prescribed medications or street drugs are not present. This just makes sense and will serve to protect YOU.
- Tramadol is a weak opioid binder but is a Schedule IV drug, and the above does NOT apply and is considered a “safe haven.”
- If you treat lots of chronic pain patients but are not a board-certified pain specialist, you may still treat your patients. The GCMB simply requires biennial pain-specific CME and to register through the GCMB with a pain license.
- The Board recognizes there will be the occasional hardship. Thus, they made a provision to relax the rules a bit as long as the specific hardship is documented. (ie-pt has had a catastrophic CVA and is wheelchair-bound, making it very difficult for transportation. Or a patient is taking less than 30mg hydrocodone or 20mg oxycodone total dose per day). In these cases, the patient could be seen only once or twice per year and monitored once per year.
- Lastly, if there is a problem with patient compliance with the above, the GCMB simply asks you to refer this patient to a pain management specialist who will have extra training, treatment options and expertise to help your patient.
“I am worried that some of my patients may be doctor shopping, and I do not have the time to call every pharmacy in town.”
Relax; you now have a friend and ally. The Prescription Drug Monitoring Program, or PDMP, is administered by the Georgia Drugs and Narcotics Agency (GDNA) in consultation with the medical board (GCMB). The PDMP began in March 2013 after two years of lobbying by several medical societies including MAG, the Georgia Society of Interventional Pain Physicians (GSIPP) and the Georgia Society of Anesthesiologists (GSA).
Specifically, this is a database that monitors the dispensing of Schedule II-V controlled substances. Once a patient fills a prescription for any controlled substance, the patient name and address as well as the pharmacy name and address are entered into the PDMP database. This way, any registered physician in Georgia can look up a patient in the PDMP to make sure there is no evidence of “doctor shopping.” It is simple to become registered, and simple to use. While I initially thought I would “bust” many of my more difficult patients, the opposite occurred. The vast majority were actually being honest with me, and I am now able to treat them better now knowing nothing fishy is going on. The PDMP is there to help you, so please use it. I use the PDMP at least five to 10 times per day.
So if after reading this and you still don’t want to deal with periodic urine drug testing, opioid contracts and periodically checking a drug database, then by all means, please refer these patients to a pain management specialist near you. We actually want to see these patients earlier rather than later, as pain specialists have many more treatment options than simply to prescribe opioids.
All I ask is when communicating with your favorite pain specialist, please show us a little love, remember, we are treating all those patients you don’t want to see anymore!