Tuesday, April 3, 2012

Pt. 4: Tales From the Trenches in the War on Pain

War on Pain What Number Am I? Or, You? by correspondent Thomas Sachy, MD, MSc

I just finished reading about Whitney Houston’s autopsy: “Whitney Houston Autopsy Reveals Heart Disease” [MedPage Today, March 26, 2012]. The cause of death was drowning, along with chronic cocaine use, smoking, and coronary artery disease. Strangely, I felt vindicated. Why should any physician have to feel that way?

Then, I came across this article: “State Cuts Doctors from Medicaid” [Honolulu Star-Advertiser, March 27, 2012]. This sounded quite ominous; three physicians who treated Medicaid patients, and were allegedly prescribing “relatively high amounts” of certain psychiatric and pain medications, were “terminated.” What does that mean? Barred from Medicaid? Medical licenses revoked? Summarily executed? Nowadays, all of these outcomes seem more and more plausible.

Pain physicians are no strangers to an existential threat — whether perceived or real — that exists because they often prescribe strong analgesics. But what’s going on with the psychiatric meds? Are psychiatrists next on the “hit list”? Apparently they are — but why? (And Lord, help me please, because I am a psychiatrist who practices pain management.)

The point man behind these controversies was U.S. Senator Charles Grassley [Iowa Republican], who has been focusing on suspected Medicaid abuses across the country. After reviewing “data” from 2008 dealing with the top 10 Hawaiian prescribers for 6 antipsychotic medications, an opioid pain reliever, and an antidepressant, Grassley, a member of the Senate Judiciary Committee, raised red flags about Medicaid abuse.

Okay, Senator, we fully recognize your concern about opioid analgesics. They can be and are abused and diverted. But what about the atypical antipsychotics and antidepressants? I haven’t heard of a “quetiapine express,” nor am I aware of sad, melancholy thugs breaking into pharmacies to abscond with antidepressants.

Here’s the rub: these medications are costly. Retail prices can run $300 to $500 per month each, and most mentally ill patients are prescribed more than one of these medications together. So I’m sure that Medicaid costs for these drugs are high. But, are these medications worth the price? You bet they are.

The 3rd generation antipsychotics do more than just ameliorate hallucinations and delusions; they are also potent antidepressants, mood stabilizers, anxiolytics, and hypnotics. And, though they are saddled with their own share of side effects — mainly metabolic in nature — they lack for the most part the terrible neurological and cognitive impairments that came with earlier antipsychotics of the 1950’s thru 70’s. The newer-generation drugs — none of which are miracle cures on their own — have proven to be lifesavers for countless patients with severe depressive disorders.

But, as noted above, the newer drugs are quite expensive. So, are these healthcare providers who treat the poor on Medicaid, and/or the patients themselves, guilty of profiting from these medications? Simply put, they most likely are not.

The prescribed meds are going to patients in need. Unless, of course, certain doctors or patients are committing fraud, such as by diverting the drugs to the black market. But, why would they do that? As of yet I am not aware of any street value for antidepressants or antipsychotics.

Apparently, Grassley was looking only at the numbers. He noted that the top prescriber of OxyContin® (here we go again) wrote nearly twice the number of prescriptions as did the second highest prescriber on the list, and greater than 4 times more than the 10th-place prescriber. Grassley also had asked each of the 50 states to provide him with lists of their top prescribers for a variety of other drugs, including Seroquel® and Zyprexa® (antipsychotics), Roxicodone® (analgesic), and Xanax® (antianxiety medication). He noted that the top prescribers of antipsychotic drugs wrote double or triple the number of prescriptions as others on the lists. He stated, “While I am sensitive to the concerns of misinterpretation of the data… the numbers themselves are quite shocking.”

Numbers? And, what’s so shocking? Prescribing a lot of something that works? And, what’s so bad about being a top prescriber? Someone has to be number one don’t they? I mean… errr… oh my God, what number am I!?

According to a pain-medication sales representative several years ago, in my State of Georgia, I was ranked as the number 6 prescriber of opioids. I was given no further details and I have no way of knowing if this fact is or was true. Neither then, nor now, was I seeking to be number one… or number 6. And, I am not presently trying to lower my ranking.

I’m sure my ranking for the newer generation psychiatric medications is up there, too. Good! And, the reason for that is, I want to help people in pain obtain relief — both physical and mental. I want them to have lives free of the fear of having to endure excruciating pain and psychological torment. That’s it… that’s all there is to it.

Regarding the psychiatric meds, Grassley also was interested in whether physicians are “overprescribing” psychiatric medications that some pharmaceutical companies have been accused of illegally promoting for unapproved uses. Again, so what!? Off-label prescribing is de rigueur — practically a necessity when it comes to effective neuropsychiatry. If the drugs work, we should prescribe them. If they don’t, patients will stop taking them or ask us not to prescribe them.

Thankfully, there was some defense of these “suspicious” doctors in Hawaii. In a letter to Grassley, Dr Kenneth Fink of the Department of Human Services who oversees Hawaii's Medicaid program wrote that some of the providers on the “hit” list worked in the state’s Adult Mental Health Division or at one of Hawaii's private inpatient mental health facilities. He stated, “Those providers deal with the most severely mentally disabled and would be expected to be outliers for psychotropic medications.”

Well… what do you know? Imagine that? Healthcare providers prescribing a lot of specialized, expensive medication in order to help the severely mentally ill. Alert congress about these renegade outliers!

Sadly, physicians who are intimidated by stories such as this are likely to become more and more fearful of prescribing those medications — fearful of prescribing what works. They will come to naturally fear that being labeled an “outlier” will be the same as being targeted as an outlaw. And, so, the suffering of those denied available and effective treatments for their conditions will get worse.

Psychiatrists can now empathize as never before with their pain management brethren. By trying to ease the suffering of their patients, some members of both groups are being chastised for doing more of that than their peers. Thus, those at the “top” of prescriber lists are marked for sacrifice to send a message that alleged overprescribing for the “right reasons” is viewed just as badly as overprescribing for criminal purposes.

Meanwhile, pain and psychiatric healthcare providers can all start nervously asking themselves: What number am I?”

Tom Sachy About the Author: Thomas Sachy has Bachelor’s Degrees in electrical engineering and in general studies, and graduate degrees in medicine [MD] and biology [MSc]. His post-graduate medical training was in psychiatry, forensic psychiatry, and behavioral neurology. Dr. Sachy practices in the state of Georgia and has completed numerous ongoing continuing medical education activities in the field of pain management and the neurosciences, and has been featured on national TV on several occasions. He is a Diplomate of the American Board of Psychiatry and Neurology.

Proviso: All observations, opinions, advice, or facts expressed above are those of the guest author, and do not necessarily reflect the positions of Pain Treatment Topics, our staff and advisors, or our educational supporters.

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