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The Grass Suffers

Tennessee has the strictest prescription guidelines for opioids in the United States. On first blush, it appears that the state is taking giant steps to stop the opioid crisis and drug overdose fatalities. I think that the concept behind the law is noble, but the substance of the law is deeply flawed. We seem to believe that the opioids are forcing themselves down the throats of patients and creating overdoses just like guns are getting into the hands of mass shooters and killing people. The difference in Tennessee, the State Legislative body, has decided that patients are somehow victims of opioids but not of guns. We will do very little to stop sales of weapons to the mentally challenged, but we will keep sane people who have no history of any opioid misuse or abuse from taking pain medication on an adequate basis.

Physicians could lose their license to practice medicine if they do not follow the guidelines. Gun dealers who sell guns to mass shooters are not vulnerable if they performed a twenty-minute background check to make sure the buyer is without a felony conviction.

Patients with chronic, unrelenting pain suffer. Pain is the only human sensation that intensifies with time. Pain is unmeasurable. Pain is real and varies from person to person. Taste is also a sensation that differs intensely. Some people are hyper-tasters. People who are hyper-tasters cannot eat certain textures or flavors because the intensity is too much. Patients who are extremely sensitive to pain are many times hyper-tasters.

Pain management is a lucrative big business. There are thousands of people in chronic, unrelenting episodic pain for any number of medical reasons. Patients in pain need help. Pain specialists are consciously numb to the symptoms of pain. Many of these physicians are trained in anesthesia and perform regional blocks for diminishing or stopping nerve-mediated pain.  Nerve blocks don’t always work; they are temporary at best. Pain specialists typically perform three of them. If none of them work, then the case is considered recalcitrant to the nerve block procedure. Opioids might be used, but pain specialists typically prescribe oral medication designed for everything else but pain such as antidepressants and antiseizure medication.

Businessmen like John Davis CEO of Comprehensive Pain Specialists (CPS) and businesswomen like Brenda Montgomery CEO of CCC Medical, Inc. are running healthcare businesses and at the same time defrauding Medicare of 4.6 million dollars or more. Comprehensive Pain Specialists is one of the largest corporate practices in the mid-south. Comprehensive Pain Specialists was established in 2005 by four physicians, including current CEO Peter Kroll and State Senator Steve Dickerson, MD, R-Nashville, an anesthesiologist. CPS still lists Dickerson as an employee on the company website. The company has 21 clinics and employs over 250 people statewide.  They are shutting down. Where will all those pain patients go? The State of Tennessee has restricted care for pain patients to the point that no physician wants to have them in their practice anymore. The State’s regulations for prescribing pain medications are the strictest in the nation. State government and our legislative body are now stepping in to regulate healthcare because the majority of those in elected positions believe they know what is best for patients in pain. Does anyone who reads this blog think that a State Senator who is in the place to author and promote State Laws and is at the same time, part owner of a sizeable multisite specialty pain practice is enjoined in a conflict of interest since pain patients must only go to his company for care?

To make matters even worse, outpatients who went to CPS were taken off their medications and told to schedule themselves for a surgically implantable pain override stimulator. None of our patients complied. Thank goodness. Administrators of CPS schooled Nurse Practitioners and office staff in promoting the neurosurgical procedure regardless of its efficacy for the pain syndrome of which the patient was afflicted. If investigators identified physicians who used these tactics in prisoners of war, the investigators would charge perpetrators of such steerage of war crimes in the first order. Why are civilians without power?

I am not supportive of State or Federal government making broad brush stroke changes for healthcare that is intended to solve a social disturbance. Drugs do not cause an addict; addicts make an addict. Guns don’t kill people; people kill people with guns. The same group of State legislators who demand restrictions on pain medications and medical practices requires freedom of speech and the right to bear arms regardless of how many children and adults lose their lives in mass shootings. Their actions show that they believe medical care is a privilege, not a right. The legislative body has the power to curtail any treatment of pain of any patient for any reason if one or two addicts could potentially get their hands-on the narcotics.

Addiction is a complex progressive condition which cannot be solved by attempting to eliminate access to legitimate opioid treatment for chronic pain to patients that need relief of their suffering. Shelby County Tennessee has no significant problem with prescription opioid abuse; heroin is our Achilles heel. The rural counties in east and middle Tennessee have a big problem with prescription drug abuse; heroin abuse in those counties is uncommon, almost rare.

There might be a thread of logic for the current approach by Governor Haslam, the State health commissioner, and our Tennessee legislative body to curb prescription opioid abuse or misuse; it is overwhelmingly irrational, however. When a state or federal government decides to funnel all patients to a finite and inadequate number of pain specialists to curb a criminal and social disturbance, businessmen like John Davis or physicians like Steve Dickerson who also are rule makers see a windfall profit just ripe for the picking. Patients suffering from chronic pain can be herded like cattle in a slaughterhouse stockyard. They have no choice but to adhere to the guidelines. Under the current law, surgeons can only give twenty days of pain medication for any operative intervention. However, many surgeons are providing only three days of pain medication since they do not wish to get involved in pain management; they perceive the situation such that it could lead to an investigation by the DEA, State Attorney General, and the Medical Board if they violate any rule. The patient suffers immensely.

The best approach to managing any socially related disturbance on a full scale is to assess the conditions which are pertinent to the problem and make every attempt to help modify those. I am unaware of the State of Tennessee Department of Human Services engaging in comprehensive evaluations of the families who had loved ones who succumbed to drug addiction. Should we assess parenting behavior? Should we evaluate medical records? Should we evaluate friendships and social media? Should we try to find out every factor that could have impacted the decision of the deceased and those surviving substance abuse to use drugs in the first place? What kind of crutch did the drug of choice provide? Did it soothe the abandonment of a mother? Did it give comfort to an abused spouse? I’m sure the undertaking would be expensive and revealing at the same time. Perhaps then we could find a better way to help those who do not recognize they need help in the first place.

Whenever two large bull elephants fight, the innocent grass beneath their feet suffer. In this case, I took an oath to relieve suffering. I’ll have to do the best I can.




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