Chronic pain management is one of the most difficult problems we encounter in the office. Physicians want to help patients with chronic pain live more productive and comfortable lives. We feel the sometimes conflicting responsibilities to adequately control pain while at the same time taking care to avoid becoming suppliers for the prescription drug abuse epidemic that is sweeping our country. More middle aged people in Washington state die of prescription drug overdose than die in motor vehicle accidents. The Agency Medical Directors Group (AMDG) in WA has proposed regulations for physicians to follow to try to more safely manage chronic pain with opioids. The AMDG slogan from their web site is:
Representatives of DSHS must have been absent from this collaboration because I was amazed to learn this week that in Washington State DSHS and Molina,the DSHS managed care plan we use at our office, refuse to pay for urine drug screening. This in and of itself may seem not unreasonable, but the reason I was so dismayed is that the AMDG regulations specifically call for urine drug testing to prevent diversion of opioids and to try to identify patients getting opioids from multiple prescribers. Specifically the proposed regulations state:
“If a decision has been made to prescribe opioids for chronic non‐cancer pain, the prescriber should get a baseline UDT and screen all patients for risk level to develop an appropriate monitoring plan as well as a basis for consultation or referral. Although UDT and other screening tools are helpful in identifying aberrant behavior, it is also important for prescribers to use their clinical judgment in the development of a monitoring plan. The Prescriber should repeat random UDT based on the patient’s risk category.”
It is clear that providers are going to be held to the standard of doing urine drug screening in patients for whom they prescribe prescription opioids for chronic pain. Failure to comply with these regulations could place a physician’s license to practice medicine at risk, and is certainly going to put physicians at risk for lawsuits if an overdose or adverse outcome happens to a patient being treated without compliance with the guidelines. So what is a physician to do in this situation. Here are a few options:
- Refuse to treat DSHS patients with opioids for chronic pain. This may not be an option because our DSHS contract demands that we treat DSHS patients with the same quality of care that we treat everyone else.
- Refuse to treat DSHS patients at all. For many this is a very attractive option because DSHS pays at the lowest rate of any third party payer, even lower than Medicare. Given one more reason to opt out may be enough to convince some busy doctors to bail on this unprofitable part of our workload.
- Refuse to treat DSHS patients unless they pay for their own urine toxicology screens. This may also not be legal, but since it is a non-covered service I think physicians could bill DSHS patients for the service as long as we get a signed consent from the patient recognizing that they are responsible for paying the fee.
- Refuse to treat chronic pain at all. This also would be attractive to many physicians since this is one of the least satisfying, most demanding, and highest risk parts of our practice. Already many patients complain that they cannot find a doctor for chronic pain management.
- Hope that this decision to refuse to pay for urine drug testing is reversed prior to full implementation of the regulations, and hope that none of our DSHS patients die in the meantime. The lack of true coordination between DSHS and AMDG is shameful. As a result WA physicians are not able to safely manage DSHS patients pain due to the payment rulings. I’m going to send this post to my state representatives and Senator to see if they have any influence to make this happen.
Every day I see incredibly stupid government regulations, but this one on chronic pain management is near the top in Washington for medical policy. Stay tuned for a future article on the refusal to allow electronic prescribing of controlled drugs by the DEA. That is dumb rule to trash another day.
I have been looking for another doctor and trying to get through to my doctor for over 2 years about the burning stabbing pain in both my shoulder blades that sometimes causes muscle spasms in the middle of my back where I can’t move. This started after a lifting injury at work. I was unable to take more than the 3 days off that I was approved and I work 2 jobs and am barely able to pull through just enough to function at work. I have tried ice, heat, massage, light relief, over the counter pain meds, herbal creams, and Flexeril from the hospital. It helped me to where I could do more besides barely make it through. My doctor won’t continue the regimen and no other doctor will see me, and it is affecting my ability to provide basic care to my clients or my pets, the conditions of my house went way downhill, I had to give up all of my hobbies because I can’t handle how painful they are now, and when I’m not working, I don’t get out of bed, and pray that the bed rest will get me ready for the week ahead, but it never does.
Stephanie Brown
Chronic pain is usually difficult to pin point. Patients often for through many many different pain management options before being put on opioids. I dislike opioids greatly, but when I can no longer take the pain, I will give in and take them and feel better quickly. Any governing board that would take away a last hope at relief is not looking out for the best interest of the patient.
Our state continues to lead the way in onerous, ill conceived and just plain stupid regulation and thus the people that need help the most continue to suffer needlessly. This happens at all levels and in many area’s of our state government.
The only way to combat this is to communicate with your state representative’s and legislators.
Finally someone else gets it!!!! Well said.