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ASA NEWSLETTER
 
 
October 1997
Volume 61
Number 10
 

Abuses and Excesses in Pain Management

Douglas G. Merrill, M.D.
Committee on Pain Management



The members of the ASA Committee on Pain Management receive mail from patients and potential patients asking for guidance on current or anticipated therapy. For the most part, our replies are either reassurance or referral to the nearest local or state anesthesia society.

We also receive mail from members of ASA, attorneys and health care payers. On occasion, this correspondence details specific pain management therapy received by patients. The majority of these descriptions reveal appropriate and professional care.

Sometimes, however, we are told of remarkable incidents of treatment which are alleged to include vast numbers of injections resulting in large monetary charges. Most often, there is a lack of improvement or a worsening of the patient's condition and an eventual acrimonious severance of the physician-patient relationship.

Each of us is responsible for the quality of care we provide individually. As ASA members, we, severally and as an organization, also hold an interest in the quality of care that all patients receive from anesthesiologists. Fortunately or unfortunately, in the field of pain management, the problems of quality of care that often concern us are not always provided by anesthesiologists.

In this article, a random sample is provided of some of the more egregious examples of poor or even negligent care that have come to our attention in the past two years.

The comments that follow these examples are solely the opinions of this author regarding some of the responses we as individuals or as representatives of the Society might suggest to local or state affiliates, hospital or medical licensure entities. These comments do not necessarily represent either the opinions of ASA or other members of the ASA Committee on Pain Management.

Case Examples
Case #1

A 50-year-old female slipped at work and fell, hitting her head and neck. Immediate evaluation in the emergency room was negative. She was diagnosed with cervical strain and was provided NSAIDs, muscle relaxants and physical therapy.

Six months later, she had not returned to work and was evaluated by a neurologist. Clinical examination, a cervical MRI and an EMG were all normal. Physical therapy was continued.

Eight more months passed, and the patient continued to complain of pain and disability. Her primary physician diagnosed "a pain syndrome with significant psychological problems." She was referred to a nonanesthesiologist physician for pain management.

Over the following 19 days, the patient reportedly underwent a course of "trigger point injections" with bupivicaine. These totaled 165 injections (eight visits). The charge for each injection was $45. Each visit also generated an "office visit" charge of $44. No other care was proffered. Total professional charges were in excess of $7,000.

There was no improvement in the patient's condition.

Case #2

A 45-year-old "disabled" female complained of back pain and presented to an anesthesiologist by self-referral. Past history included "three episodes of RSD," a diagnosis of fibromyalgia, multiple abdominal surgeries for "pelvic pain" and a long history of chronic back pain.

Evaluation revealed a "normal neurological exam" and normal MRI of the lumbar spine. Examination further revealed "tender trigger points and S.I. joint and trochanteric bursae pain."

Over the following six weeks, she had 31 visits, underwent 35 "bursae" injections (40mg triamcinolone each time), seven lumbar epidural injections (40mg triamcinolone), more than 90 "trigger point injections" and 28 "physical therapy" sessions, consisting of applications of hot packs.

Total professional fees were $12,100. Facility fees were an additional $10,400. There was no change in outcome. The patient was dropped from treatment when Medicare denied further claims.

Case #3

A 55-year-old female presented by self-referral for a complaint of "low back pain for years." The anesthesiologist recorded her exam as "normal, except for tenderness with palpation over the SI joints and the facet joints at L4-5". No radiological exams were obtained. Over the next seven months, the following therapies were applied:

    • 13 caudal and thoracic epidural "sympathetic and steroid" injections
    • 20 caudal morphine injections
    • 40 visits that resulted in multiple trigger point injections
    • five lumbar phenol facet joint injections
    • one caudal hypertonic saline injection
    • condition was unchanged. The bill for professional fees was in excess of $50,000, and the facility fees were in excess of $34,000.

Her care was terminated by the practitioner (after his letter to the insurance company declared that her need for continued hypertonic saline injections was unequivocal) when the insurance company began to deny the claims.

Case #4

A 26-year-old male presented by self-referral to an anesthesiologist with a complaint of a six-year history of headache. He was receiving opioids for this condition from another physician. No attempt was made to contact that physician or the primary care physician.

Examination records indicated a "tender occipital nerve" and nothing else. MRI and cervical spine plane films were read as "normal." Over the following 12 months, the patient was given:

    • five "hyper-oxygenation" therapy sessions
    • four occipital cryo-therapies
    • four sphenopalatine blocks
    • 20 caudal morphine injection prescriptions for Fioricet, Roxicet, Percocet, Darvocet, Valium and Duragesic patches

The exact costs of this therapy are unknown. There was no change in the patient's pain.

The practitioner requested that the insurance company approve the placement of an intra-spinal morphine pump. When that request was rejected, the patient was discharged from the practice and diagnosed as "drug-seeking."

System Problems

Individual practitioners who practice in a questionable manner as described here are often abetted by problems in the system. The tort system, for instance, often rewards the most invasive approach to pain management because no treatment guidelines are in effect, and the "gatekeeper" (plaintiff's attorney) may have a vested interest in higher costs. This interest exists because higher costs increase the appearance of injury and also the value of the "damages," a percentage of which may determine the fee of the attorney.

The system is also flawed because the majority of third-party payers do not subscribe to treatment guidelines, require outcome measures or mandate second opinions in this area of medicine. While the general use of these measures has itself not been evaluated for efficacy in improving outcomes in pain patients, such steps clearly could have avoided some of the abuses described here.

The uncertainties of diagnosis inherent in pain management and the attempts of good scientists to investigate and decrease that uncertainty have also been abused. For example, the current conundrum regarding the best diagnostic criteria to establish the presence of Chronic Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RSD) or Sympathetically Mediated Pain has opened the door to some remarkable abuses of invasive therapies.

Two cases were reviewed by this author wherein the practitioners relied upon the more inclusive definition of CRPS 1 to justify "aggressive" therapy. Multiple invasive, expensive and potentially dangerous sympatholytic and other procedures were performed over the course of years in litigating patients who had few or no physical findings and who only received short term "improvement" from each injection. The fact that the patients were complaining of pain was deemed to be sufficient evidence of this "new" CRPS, resulting in large numbers of random injections.

The membership is to be assured that abuse has not been avoided by either fellowship education in pain management or the certification of Added Qualifications in Pain Management by the American Board of Anesthesiology. Some of the most impressive educations have preceded some of the most tragic abuse cases reported.

Recommendations

Institutions offering pain services often seek input on suggested policies regarding pain management in hospitals or clinics. Here are a few that would characterize a non-abusive pain management service or clinic:

  1. There is examination of each patient. The literature supports the thesis that a significant impact can be made upon patients' outcomes with this simple technique.
  2. All possible records from other physicians who are caring for the patient are obtained. This obviously will avoid conflicting treatment, duplication of treatment and confusion for the patient.
  3. Creation and use of treatment guidelines, including pre-set criteria and intervals for treatment plan re-evaluations.
  4. Creation or subscription to validated outcome measures and employment of those results in recurrent re-evaluation of the treatment guidelines.
  5. Institution of new procedures is done in the environment of an Institutional Review Board or its equivalent and full disclosure to the patient is provided with regard to the technique's lack of scientifically proven validity as well as the practitioner's own inexperience with the technique.
  6. Relationships are established with local practitioners in the fields of behavioral medicine, neurology, physical therapy, occupational and rehabilitation medicine, and the surgical specialties. Referrals to these practitioners are made when patients do not improve with initial efforts or in any complex presentation. Also, repeated re-evaluation of the efficacy of the efforts of these other practitioners is done.
  7. If the decision is made to accept self-referrals, it is noted that the majority of this population does not require injections as the first line of therapy.
  8. Patients for whom opioids are prescribed for other than cancer-related pain or post-treatment "rebound" pain, should be seen regularly, should be on a contract and should be held to the tenets of that contract. The clinic may also consider contacting the local office of the DEA and the local state licensure board to acquaint them with this practice and to make certain that any additional requirements which they might have are fulfilled.
  9. Finally, Dr. Bonica's advice should be remembered when evaluating the role of injection therapy in the care of any patient: "Blocks are continued until the patient is completely cured or reaches a plateau with this form of therapy." (my emphasis)l
Conclusion

The majority of our Society's members provide excellent care to their patients. However, abuse does exist and is, on occasion, remarkable. All too often, policies of both governmental and payer organizations are created in response to such abuse. Unfortunately, such responses are frequently excessive themselves and can actually obstruct the delivery of good care to patients in pain.

Therefore, on behalf of our patients, it seems incumbent on each of us and upon our specialty societies to maintain rigorous standards in the approach to pain management. In this way, those few who do abuse their patients will become starkly apparent as aberrations. Hopefully, then, their actions will not drive the creation of health care policy which might impede the care of our patients.

References

1. Bonica JJ. ed. The Management of Pain. 2nd ed. Philadelphia: Lea & Febiger; 1990:236.


Table 1
Profiles of Abuse

The cases noted in this article are representative of many which, when gleaned for common aspects, can be used to create a profile of the "abusive" pain management practitioner. Please recognize that no one item on the following list is of itself indicative of abuse. However, the presence of a majority of them in any one practice should raise the possibility that the pattern of that practice should be re-evaluated.

Common aspects of practices that have been associated with abuse include:

  1. The practice is, in large part, self-referral in nature.
  2. Appropriate history evaluation and physical examination is either markedly abbreviated or is not considered in the decision to provide therapy.
  3. Almost all patients receive injections, even in a self-referral-based practice.
  4. A majority of patients receive sedation or are "anesthetized" for all injections.
  5. Both improvement and lack of improvement in the patient's condition is perceived as an indication for further injections or increasingly invasive injection therapy, never as grounds for re-evaluation or inclusion of other specialists (e.g., behavioral medicine).
  6. Second opinions are never obtained, and treatment plans are not routinely reviewed when therapy is ineffective or more invasive steps are contemplated.
  7. A multidisciplinary approach to pain management is never used or consists solely of "physical therapy," which primarily includes modality applications (e.g., ultra-sound, electrical stimulation, heat).
  8. The other physicians caring for the patient are generally not contacted and past treatment records are not obtained.
  9. The work takes place primarily in freestanding centers where there is no peer review by other pain practitioners who do not have a financial incentive to approve it. As well, the practitioners tend to be either owners of the facility or are compensated for the use of modalities (e.g., fluoroscopy) or for the number of procedures performed or patients seen. The practitioner routinely "unbundles" drug, anesthesia and radiology charges.
  10. Outcome measures are neither used or reported.


Douglas G. Merrill, M.D., is Director of Valley Analgesia Service, Valley Anesthesiology Consultants, Phoenix, Arizona.
E-mail the author.

 


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The views expressed herein are those of the authors and do not necessarily represent or reflect the views, policies or actions of the American Society of Anesthesiologists.

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