The Controlled Substance Witch Hunts in Florida

Florida State SealI care for a 65 year old woman suffering with sarcoidosis affecting her lungs, her skin, her bones, her nerves, her blood chemistries, her kidneys, her colon and her mind. She has gone from an active spouse, mother, grandmother, tearing up the dance floors with her husband, to a home recluse calling friends to drive her to medical and care appointments while ambulating with assistance of another strong individual supported by a 4 wheel walker with a seat. She describes her foot pain as feet burning on fire. An evaluation with the Cleveland Clinic and ultimate biopsies of her skin and nerves led to a diagnosis of severe small vessel polyneuropathy. An experimental course of an IV immunosuppressant provided short term relief and hope for relief of pain but those drugs effectiveness waned quickly. She has recurrent kidney stones from sarcoidosis effect on her calcium metabolism and is in chronic and recurring pain with frightening blood in her urine as small sharp kidney stones wind their way down her ureters towards her bladder. She has had colitis for twenty years now. Normal barium enemas and colonoscopies initially resulted in her being considered a neurotic quack. When the Mayo Clinic suggested a biopsy on the normal colon and the pathology revealed a new entity responsible for all her symptoms she was reclassified from a neurotic annoying wife of a professional to “an interesting and rare case” by many in the medical community. Throughout her trials and tribulations she has sought the care of board certified gastroenterologists, nephrologists, urologists, rheumatologists, psychiatrists, psychologists, ophthalmologists, dermatologists, general internists and a neurologist specializing in pain management.

The State of Florida suffered through an epidemic of illegal pill mills at the turn of the century. Criminals hired criminal physicians to prescribe narcotic pain pills for cash irrespective of a justifiable medical condition or medical exam. These prescribing practices were spurred on by a “blue ribbon “physician panel (financed by the same pharmaceutical firms who made the pain pills) suggesting doctors use more narcotics and less nonsteroidal anti-inflammatory medicines to control chronic pain. They additionally encouraged supplementing your income by dispensing pain pills in addition to prescribing medications. I never believed in that because there was too much opportunity and room for inappropriate prescribing.

Our unfortunate chronic patient had her pain controlled by a board certified neurologist who through trial and error found a formulary that the patient tolerated. During the months of experimentation the patient suffered through nausea, vomiting, constipation, diarrhea and dehydration. Trips to the ER for anti-nausea medications or IV hydration were frequent and common. When her neurologist found a mix that worked he stuck with it. That patient’s pain doctor moved out of the state of Florida 3 years ago because he was afraid that the implementation of the Florida pain law would limit his patients’ access to needed medications and make his prescribing subject to inappropriate review and scrutiny. He is currently working at a university medical center in North Carolina providing patient care and teaching medical students and doctors in training.

As the patient’s primary care physician I became the narcotic prescriber for the patient in her neurologist’s absence. The patient executed a pain contract with our office which she has followed religiously while she continued her care with her multiple specialty doctors. We tried several other neurologists and pain physicians but the high volume impersonal nature of medicine today left her unhappy and dissatisfied with the care and attention provided.

When the patient turned 65 years old and went on Medicare she purchased a Medicare Part D prescription drug plan which directed her to a large chain pharmacy. They told her they would not prescribe her narcotics because they did not want the liability and did not like the combination of medications ordered by her board certified pain specialist. That company had been fined for illegally selling pills without prescriptions to drug dealers out of their Samford, Florida distribution site. The alternative pharmacy, a popular supermarket chain was audited by state regulators this week. The auditors were upset with the pharmacy releasing a controlled substance in the quantity given especially along with her antianxiety and anti-migraine headache medicines on this patient’s medication list. They had no patient records or history to explain why she was receiving these scripts, but nonetheless so intimidated the pharmacy that they called the patient and told her they would no longer be able to sell her the prescribed pain medicines. The patient called my office in tears wondering where to obtain her medications and frightened about the prospects of abruptly stopping these medications. The pharmacy simply said the liability and fear of losing their license necessitated the change in policy.

I am a board certified physician in internal medicine, with extra study in Geriatrics who has practiced in this community for 36 years. I list on my medical license application every 2 years that I will prescribe pain medications for legitimate chronic conditions. I take my required continuing education courses especially in the areas of prescription pain medication to meet the state requirements. My patients who receive chronic pain medications must execute a pain medicine contract which outlines their responsibilities as well as mine. I do not take lightly the prescribing of a controlled substance, but recognize that sometimes there are medical conditions which leave you with no other options. I have been told that after the state regulators look at the pharmacies role in prescribing short term narcotics for long term use, they will be contacting the Florida Board of Medicine to review my prescribing of these medications for this patient. It is clearly an attempt to coerce and intimidate at the expense of a sick and vulnerable group of patients. I have probably prescribed fewer pain medications in my 35 year career than a pill mill prescribed in one day of business. The response to the Florida Board of Medicine will require hiring an attorney and involve time, research and aggravation. Our legislators, prosecutors and law enforcement officers should be able to differentiate between a functioning medical practice and an illegal pill dispensary. I am beginning to believe these same officials could not recognize the difference between a house of worship and a functioning brothel. Their inadequacies and inefficiencies threaten to prevent the citizens of Florida from receiving relief from pain even if they have a legitimate reason for receiving pain medication on a long term basis. Do the citizens of Florida want their doctors making these decisions or legislators and bureaucrats with no clinical patient care experience?

Weight Loss May Prevent Recurrent Atrial Fibrillation

Heart - CopyAtrial fibrillation is a chaotic heart rhythm seen generally in patients with an enlarged left atrium chamber of the heart and or disease of the heart valves. The heart beats irregularly in many cases decreasing the effective pumping ability of the heart muscle. Patients with atrial fibrillation tend to form blood clots in the left heart chambers which are at risk to break off and travel downstream especially to the brain causing embolic strokes. Newly diagnosed patients are placed on anticoagulant medications such as warfarin, dabigatrin, rivaroxaban, or apixaban to prevent these clots from forming in addition to medicines to slow down the heart rate and hopefully shift you back to your normal heart sinus rhythm in time. Other patients are forced to undergo electrical shock cardioversion to re-establish their normal sinus rhythm while others require ablation therapy to do the same. Once these procedures and chemical maneuvers have been successful, and many times they are not, patients are placed on medications to maintain the correct rhythm.

At a meeting of the American College of Cardiology, Rajeev K. Pathak, MBBS, of Australia’s Royal Adelaide Hospital, presented data showing patients who went on a diet and lost 10% of their body weight were six times more likely to be free from the arrhythmia without having to use antiarrythmic medication at five years (rate 46% versus 13% with less than a 3% weight loss.) The results were presented at the ACC meeting and published in the Journal of the American College of Cardiology.

The study looked at 355 patients who had atrial fibrillation and a body mass index of 27kg/m2 or greater. They were offered a low fat, low carbohydrate weight loss program plus an exercise program at a weight loss clinic. They determined freedom from recurrent atrial fibrillation by using a seven day Holter monitor recording. The evaluations showed that those patients who kept the weight off with less than a 2% fluctuation in weight were 85% more likely to not have recurrent atrial fibrillation or require medication use to control their rhythm.

Lifestyle modification in the form of weight loss is always preferable to the use of medication and procedures. Bernard Gersh, J. MBChB, DPhil, of the Mayo Clinic in Rochester, Minnesota was adamant in saying, “Bottom line is this is a very simple strategy for people with atrial fibrillation. They must lose weight.” He went on to say that weight loss should be considered and tried before a patient is sent for an ablation procedure.

It is important to note that this study is an observational study and did not actually prove that losing weight caused atrial fibrillation to disappear. A further study is underway to prove this point. The article additionally did not specify if the researchers discontinued anticoagulants in the weight loss group no longer exhibiting atrial fibrillation.