I never intended myself to be immersed in the “pill Mill” controversy. In somewhat of a paradox I am. Rather a career in politics and law in the early ’70’s, I became a psychotherapist by choice because my best friend committed suicide after unbeknownst to him, he becoming high on amphetamines and vodka mixed together and taunted to drink. I made a choice to make a difference. But my solo training in family practice clinics in Appalachia hours away from substance abuse and mental health professionals brought me face to face with the Oxycontin abuse in 2000.
One of my clinics was targeted for the prescribing of Oxycontin by the physicians who worked for me. Over 6,000 patient charts were reviewed by the federal task force for two years. It cost me $58,000 in legal and copying fees. After the investigation, my lawyer received a call from the Assistant U.S. Attorney who said “you can have Coates come get his charts. We didn’t find one case of prescription abuse.”My attorney convinced the AUSA to deliver them to me at her cost.
How did it happen that not one non compliant prescriptive case could not be found? It is simple.Fifteen years ago my physicians were audited by my compliance staff. We had mandated enforceable protocols in the clinic and one of the protocols was the physician had to state on the record by signature he/she examined the patient and the medication was necessary and required. All other means of treatment had demonstrably failed. The audits confirmed independent evidence of failed treatments. The physician also was required to state on his timesheet compliance with all laws and rules governing their practice. Each pay period the docs had to attest compliance.
We had a second layer of safety which protected the physician. We protected the physician from the patient. Every patient was evaluated by a licensed behavioral practitioner as to the need for narcotics and even psychotropic medication, including benzodiazepines and anti depressant medication. We had on site a confirmation moderate complexity clinical laboratory which tested urine and blood for toxicology. We tested for alcohol abuse. Point of service cups have a 40% error rate; 20% false positive and 20% false negative. We confirmed testing to protect the physician.
After teaching about 150 physicians and staff in Florida regarding compliance with the Florida Legislation the past five years, evaluating personally almost 2,000 individual patients for compliance, and averaging the reading of approximately 6 news articles about “pill mills” daily, I can readily make the observation neither the physicians or patients are safe in this country when it comes to narcotic prescribing. Our good physicians are frightened to the point of fear of being prosecuted; most deserving patients are not even sure that they will have their script filled, and those patients working the system wont stop at anything to try scamming the physician. I have not informed you of anything new.
But maybe there is a solution so obvious it may be automatically rejected. The tools necessary are available in every clinic that has a computer. Just add required compliance audits similar to JCAHO or CARF. Audit the Physician AND the patient on multiple levels a minimum of once a year. Would it surprise the reader to hear that even in the best pain management clinics 60% of the patients are currently NOT following the physicians plan of care for prescription narcotics? That is the number Pulido Coates and Associates has discovered to both the shock and dismay of their physician clients. Wait just a minute before you make a deduction. It isn’t hard to fix. the disease of pain must be managed. And compliance with the plan of care requires education. Enter the Advanced Nurse Practitioner. Florida is one of the few states preventing prescriptive authority to the one group of healthcare professionals that are trained to take the time, expertise, and hard-line questioning to “audit” the patient’s compliance, AND to watch the doctors back.
I believe pain management clinics ought to treat non malignant chronic pain as a course of “disease management”. The protocol needs that skilled professional, the Advanced Registered Nurse Practitioner, to audit the patient, which by the way, is a five step reimbursed procedure, paid for by Medicare, Medicaid, and most commercial insurance plans. I have seen this work. I know it works. In those clinics Pulido Coates has instituted the disease management protocol we call the Pain Patient Compliance Protocol two things are objectively reported: Doctors sleep better at night, and patients begin to get the mandate to follow strictly the physicians pan of care. The rate of non compliance drops like a rock to less than five percent. Doc’s, protect your ticket to practice. Patients, try wanting to get well.
Those interested in finding out more about this approach can review the pain management page of the SyMedica Network.