call their bluff with a letter from attorney ?

Harmful effects of UNTREATED PAIN

I can’t count the number of times that I have heard from chronic pain pts that their prescriber is reducing their dose or eliminating their dose all together. Or the prescriber tells the pt that they must or must not do something because it is “the law ” when in fact it is now the policy of their practice or the healthcare system that they work for… has nothing to do any law.

Here is a chart that list the extensive effects that under/untreated pain has on various bodily functions and/or the pt’s comorbidity issues and this chart was composed almost TEN YEARS AGO… so it is not something that is new and most healthcare professionals should be aware of the issue that it contains.

When a pt gets this sort of edit of their medications are being reduced.  Their time to act to get things rectified could be a rather short window of opportunity. The pt should not say anything when given this edit, but should contact an attorney, probably one that deals with civil rights & discrimination.  If the prescriber is not reducing the pt’s other medications but just focusing on controls.

If I was a pt in this position, on my way out of the office, I would ask for a printout of the prescriber’s clinical notes for this visit.  In healthcare there is this saying, “if it is not documented… it didn’t happen”. If the only documentation that shows is the reducing of the dose – without any clinical reason – or – just claims they are following cdc guidelines… or no reason at all because they are following some corporate edict that they have been told not to disclose.

I am not an attorney and I may be way off base but what I am suggesting is a relative inexpensive initial step – a couple of hundred dollars.

This letter may end up being sent to a prescriber/healthcare corporation, pharmacy/pharmacist, insurance company, PBM.

My idea is just a letter to put those entities ON NOTICE that if the pt is harmed/dies from a reduction/elimination of controlled meds – especially they are intentional thrown into a cold turkey withdrawal. That there could be consequences for their actions.

If the entity claims that there are no studies that shows that opiates are beneficial to pts for long term use… here is a TEN YEAR study from the early 2000’s that documents otherwise

Opioid Treatment 10-year Longevity Survey Final Report

If the entity is just claiming that they are following the “law” in regards to max MME’s/day…

Here is a MME conversion program that I use for reference

https://globalrph.com/medcalcs/opioid-pain-management-converter-advanced/

and here is footnotes from the same prgm all MME conversion programs will have same/similar footnotes, basically these footnotes suggests that on a “good day” these MME conversion programs are JUNK SCIENCE.

  • Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Dosage titration of the new opioid should be completed slowly and with frequent monitoring. 
  • Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of opioids.
  • The amount of residual drug in the patient’s system must be accounted for. Example: fentanyl will continue to be released from the skin 12 to 36 hours after removal of the patch. Residual effects from discontinued long-acting formulations should also be assessed before converting a patient to a new opioid.

If the entity states that 90 MME/day is the CDC guidelines and/or “it is the law”… here is quotes from the CDC 2016 opiate dosing guidelines:

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”

“Clinicians should consider the circumstances and unique needs of each patient when providing care.”

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”

Then if the entity has not taken into consideration the pt’s CYP-450 opiate metabolism status, then all of the pt’s health issues has not been considered.

Here is a article about CYP-450 opiate metabolism rates .. this is just one of many articles available

https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/making-practical-sense-cytochrome-p450

In sending this letter to these various entities, the attorney should consider a statement that being discharged from the practice will be consider a act of retaliation and/or pt abandonment and may result in further legal action against the entity.

If Epidural Spinal Injections (ESI)   are involved and the entity is mandating that the pt is required to get oral opiates they MUST SUBMIT to having ESI done.

Here is just one of many articles about the FDA’s  https://livelovefruit.com/dangers-epidural-steroid-injections/      FDA Warns About Dangers of Epidural Steroid Injections for Back Pain

The side effects of epidural steroid injections are so severe that the FDA ruled that all injectable steroid must carry an updated warning that includes the above risks, as well as “arachnoiditis, bowel/bladder dysfunction, headache, meningitis, paraparesis/paraplegia, seizure, [and] sensory disturbances (6).”

The FDA’s website also warns that “the effectiveness and safety of injection of corticosteroids into the epidural space of the spine have not been established, and FDA has not approved corticosteroids for this use (7).” This is largely due to the fact that research into the risks of epidural steroid injections is still being conducted. Approved or not, Dennis Capolongo of the ENDC, a ground that has campaigned against epidural steroid injections for years, believes that warning labels need to be stronger, and more visible – not just confined to the small print.

Then there is the issue of if the entity states that “no ESI’s … no oral opiates” … there is a portion of the Sherman Antitrust Act called TYING COMMERCE

https://en.wikipedia.org/wiki/Tying_(commerce)

This law basically states that it is illegal for a vendor to force a customer to purchase something that they don’t want in order to purchase something that they do want.

If the pt gets little or no benefit from these ESI’s then there is the question of Medicare/Medicaid law on inducement to cause a pt to cause Medicare/Medicaid to be charged for services that are not medically necessary https://benkofflaw.com/practice-areas/federal-and-state-anti-kickback-and-inducement-laws/

Then there is possibly the final “notice” to the entity… if the pt becomes incapacitate, dies or commits suicide then there is a possible legal recourse by the spouse and children 

This is probably the last thing that the entity will ever consider … being sued by the spouse and/or children of the pt.

A good law firm may see that a single letter to one set of healthcare entities have the distinct possibility of turning into a large class action lawsuit, since it is unlikely that the healthcare entity is doing this to just one or even a handful of pts, but more likely all similar pts in the practice or when it comes to large healthcare corporations, chain pharmacies, insurance/PBM companies could be applying this to thousands and/or tens of thousands  pts.

What I am suggesting is what prosecuting attorneys do to criminals… they “over charge” with the hopes that they will end up pleading guilty to one-two charges and/or if they go to trial… they will get a guilty verdict on one or two charges.

Any pt that attempts to talk to a law firm about being poorly treated for total denial of care… don’t talk to them about malpractice or let them go down that path… many states have caps on award for malpractice and each side hires a “expert” that will testify that who hired them was doing the correct thing… because of the award caps, most law firms will not even cover their expenses – if the take the case on a contingency basis – even if they win.

The look for a large number of people in a class action against a entity with deep pockets. IMO, sending the offending healthcare entity a letter of notice of the potential harm that could happen to a pt.. then they have been harmed and things may move from malpractice to known intent…  Intentionally and knowingly throwing a chronic pain pts – particularly a intractable chronic pain pts into cold turkey withdrawal and the pt ends up with a heart attack, failing kidneys, stroke, suicide or death… the $$$ damages should be greatly increased and if their is a spouse and children left behind or required to care for a loved one who is no longer self reliant and has to be cared for… that is financial damages…

 

Could suicides help the chronic pain community to better pain management ?

 

 

 

 

4 Responses

  1. […] Would the estate of this pt have a better legal case if they had done something like I suggested in this post call their bluff with a letter from attorney ? […]

  2. Great idea!
    A patient (pt) contacting a lawyer could say something to the effect of;

    ‘I’m concerned about the known, harmful effects of living in severe pain and am currently not being treated appropriately.

    I’ve included a list of the known effects, as well as an exact copy of the CDC guidelines, as it pertains to chronic pain and the 90MME cap my current physician’s employer is forcing them to apply.’

    The pt may also want to include a few short notes about their individual diagnosis/es, to show the correlation between the effects of being forced to live in severe pain and how it directly impacts their health, for example;

    If the patient already has heart disease and/or an immune disorder, be sure to point out how being undertreated, or untreated, for pain is harming them as per their diagnosis, and is in complete opposition as to standards of care and why healthcare providers exist in the the first place.

    If just a few lawyers would be willing to write a letter, and this sounds like an excellent loophole through the monetary cap issues for a class action suit (though I’m also not a lawyer)- and enough pts are willing & able to become involved, this could be a great way to move forward, especially in states that have recently passed laws to help protect compassionate prescribers.

    Thank you Steve, you’re always thinking & have a great archive of info and facts.

  3. Right on the button as usual Steve. Fantastic Work!!!!

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