Dr. James Schaller, MD
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Real World Clinician Reproves Silly Pennsylvania Licensing Board on Pain Rules

Sunday, February 7, 2010

"Irresponsible" Opioid Prescribing

I received a letter from the Chairman of the Pennsylvania Medical Licensing Board. He endorsed the book, Responsible Opioid Prescribing, by Scott Fishman, with the imprimatur of the Federation of State Medical Boards. I suggest the following in response to this garbage.

[This blog post is] an all out legal counterattack on the enemies of clinical care, including the members of the Licensing Boards, the Federation of State Medical Boards, and any other garbage guideline peddler. The innocent defendant should have no feeling of mercy in defending clinical care from garbage guidelines and attempts at intimidation of the doctor [to exit any role in] pain management. The list below [of expectations] takes dozens of hours a patient, and will deter all but a few specialists. The sponsors should also be named:

  • Abbott Laboratories
  • Alliance of State Pain Initiatives
  • Alpharma Pharmaceuticals LLC
  • American Academy of Pain Medicine
  • American Cancer Society
  • American Pain Foundation
  • American Society for Pain Management Nursing
  • Candlelighters Childhood Cancer Foundation
  • Center for Practical Bioethics
  • Cephalon, Inc.
  • Endo Pharmaceuticals*
  • Federation of State Medical Boards Research and Education Foundation
  • International Association for Pain and Chemical Dependency
  • King Pharmaceuticals
  • Lance Armstrong Foundation
  • Mayday Fund
  • National Pain Foundation
  • Pain and Policy Studies Group, University of Wisconsin
  • Purdue Pharma L.P.
  • SAMHSA/CSAT (Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment)

These oppressors of clinical care should be held accountable for their interference with clinical care. If any doctor is persecuted for trying to relieve the chronic and impairing pain, insist that the defense lawyer attack the persecutors.

  1. Total e-discovery of all personal and government computers of the licensing board prosecutor, and of all members of the licensing board, and of all policy, responsible officials above them in the department.
  2. Demand all pain management records of every member of the licensing board, of Dr. Fishman. If any record, fails to contain any single element listed below, file charges of unprofessional conduct against the doctors and report them, not just to their respective licensing boards, but to the Drug Enforcement Administration.
  3. Demand all evidence that the content or quality of records has any correlation with outcome or with any other indicator of quality of care. It does not correlate. These paper shufflers have no justification for their standards.
  4. Racial discrimination. The undue burden of this garbage text will cause delays and preclusion of patients in agony. The unnecessary time requirement and high fees will all but exclude everyone on Medicaid. Because people with dark skins are over-represented in such groups, this book is inherently racist. Rich white people can afford to have the requirement met below. Poor darker folks in agony, may rot in agony, this book is implying.
  5. Organized medicine should seek to enjoin these garbage guidelines because they will bring pain management to a standstill, and violate the revised ADA.

From the book, the FSMB model policy 2004_grpol_Controlled_Substances.pdf requires the following. The more difficult the patient, the more time should be allotted. Get into the circumstances of the patient's difficult life. Just repeat what the patient is saying in reflective listening.

Evaluation: comprehensive history (pain location, character, maximum and minimums, onset, exacerbation, amelioration, effect on sleep, mood, work, relationships, sex, recreation, involvement in litigation), physical examination (definition not established), screening for drug addiction (nothing established as standard, CAGE, drug and alcohol evaluation).

Treatment Planning: objective measurements, multiple functional improvements required, reconditioning, not elimination of pain or big score decreases, revisions of functional treatment plans.

Informed Consent and Agreement to Treatment: collaborative decisions, expected outcomes, goals, informed consent, education about the risks and benefits , need to inform doctor of side effects, use of other medications, changes, time of agreement, consent to communicate with other health providers, where agreement kept, privacy rights, administrative details, missed appointments, single pharmacy use, emergencies, terms of termination, abuse, violating agreement, inappropriate behaviors, no improvement, pregnancy, tolerance, toxicity, overdosing, medication seeking, selling medication, stopping abruptly, limit on replacing lost medication, limit on refills, random urine screens, education on withdrawal and on tolerance, addiction risks and behaviors, single pharmacy, drug interactions, masking, driving, misuse, legal consideration, specifics of prescriptions.

Periodic Review: functional goals, adherence, lab testing, pseudo-addictive behavior from inadequate pain relief, listening, attention to entire patient, referral, adjustment of doses, modification of goals, revisions of agreement, complete documentation with descriptions of risks of actions and of inactions.

Consultation: do early, gather records and data for consultant's use, request specifics, plan, communicate with consultant, inappropriate patient behavior, listening, non-confrontational approach, avoid talking down, include the patient in decisions, look at contexts, set limits on behavior, maintain safety, terminate with a witness, send letter, tapering of drugs causing withdrawal.

Medical Records: assessment, treatment agreements, education, action plans, outcomes, monitoring, history and physical, test results, consultations, reviews, medications, pain intensity levels, levels of functioning, subjective complaints, objective findings, diagnosis, treatment objectives, discussion of risks and benefits, informed consent, instructions and agreements, plans for review.

Compliance with Controlled Substances Laws and Regulations: The content of the 67 page DEA manual pract_manual012508.pdf

AUTHORED BY DAVID BEHAR, MD, EJD

DR. SCHALLER NEITHER OPPOSES NOR SUPPORTS THIS OPINION ABOVE.

HE DEFERS TO CLINICIANS DOING NON-INTERVENTIONAL PAIN CARE AND WHO PRESCRIBE NARCOTICS FOR FULL PAIN CONTROL AND WHO SEEK TO AVOID SUICIDE BY PAIN FOR THEIR REFLECTIONS ON THIS MATERIAL. IN OTHER WORDS, CLINICIANS THAT READ THE MERE PDR ON THE ABSENSE OF AN UPPER ARBITRARY MAGIC TOP DOSING IN THE ABSCENSE OF SIDE EFFECTS.

HE ALSO DEFERS TO THE 50 MILLION CHRONIC PAIN PATIENTS IN THE USA.

DR. SCHALLER FEELS THE MEMBERS OF THE GOVERNMENT, THE MEDICAL COMMUNITY AND THE LEGAL ESTABLISHMENT WHO SET POSITIONS ON CHRONIC AND SEVERE PAIN, SHOULD HAVE CHRONIC AND SEVERE PAIN THEMSELVES.


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