October 1997
Volume 61 |
Number 10
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| 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:
- 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.
- 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.
- Creation and use of treatment guidelines, including pre-set
criteria and intervals for treatment plan re-evaluations.
- Creation or subscription to validated outcome measures and
employment of those results in recurrent re-evaluation of the
treatment guidelines.
- 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.
- 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.
- 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.
- 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.
- 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:
- The practice is, in large part, self-referral in nature.
- Appropriate history evaluation and physical examination is
either markedly abbreviated or is not considered in the decision
to provide therapy.
- Almost all patients receive injections, even in a self-referral-based
practice.
- A majority of patients receive sedation or are "anesthetized"
for all injections.
- 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).
- Second opinions are never obtained, and treatment plans are
not routinely reviewed when therapy is ineffective or more invasive
steps are contemplated.
- 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).
- The other physicians caring for the patient are generally
not contacted and past treatment records are not obtained.
- 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.
- 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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