As the overdose crisis has worsened, doctors are under increasing pressure from law enforcement, regulators and insurers to reduce or stop prescribing opioids.
A nurse practitioner in the Seattle area – who asked to remain anonymous — recently told us that she was closing her pain clinic because she was afraid of losing her license and going to prison.
“This whole thing is making me literally sick to my stomach. I’ve cried a million tears for my patients already, and I’m just beginning,” she wrote.
“I will be carefully weaning them all down… or arranging transfer of care to anywhere the patient would like. What a joke that is. There is no one else prescribing effective doses of opioids for chronic pain patients. If I am to be thrown in prison, it should be for that — not for keeping them on therapy that enriches their lives.”
Patient abandonment is a growing problem in the pain community. Patients safely prescribed opioids for years are being dropped by doctors – often without weaning or tapering — after they fail a drug test, miss a pill count, or become disruptive during an appointment. Sometimes they’re dropped for no reason at all.
Such is the case of Chris Armstrong, a 50-year old Orlando, Florida man severely disabled by multiple sclerosis and trigeminal neuralgia, a chronic pain facial disorder sometimes called the “suicide disease.” For over six years, Armstrong’s pain was treated with relatively high doses of morphine and hydrocodone at Prospira’s National Pain Institute in Winter Park.
That came to abrupt ending in late December, when Armstrong’s 74-year old mother and caretaker was handed a brief letter during their last visit to the clinic.
“This letter is to inform you that I will no longer be your physician and will stop providing medical care to you,” wrote Cherian Sajan, MD. “I will continue to provide routine emergency and medical care to you over the next 30 days while you seek another physician.”
No explanation was given for Armstrong’s dismissal. Dr. Sajan did not respond to a request for comment.
“To have the plug pulled just like that,“ says Chris. “There’s nothing in my record that I’ve ever done anything wrong. I was a model patient.”
“They discharged him and gave no reason,” Valerie Armstrong said. “They gave us a name of another pain doctor which they scribbled on a piece of torn paper. We went to see him, but after a few visits, (that doctor) told my son he was discharging him as well, as he needs ‘long term care’ which they refuse to provide.”
At the National Pain Institute, Armstrong says he was prescribed 150 morphine equivalent units (MME) of opioid medication daily. The second doctor reduced that dose to 100 MME – still above the maximum dose of 90 MME recommended by the CDC.
Chris has been unable to find a new doctor and believes he’s been red flagged as a patient who needs high doses of opioids.
“I went to another one and he said he can’t do anything because his hands are tied because I’ve been ousted by another pain doctor,” he told PNN. “What am I going to do, if no one will see me because of that?”
“I have called every pain clinic in my area and no one will see my son because he has been discharged by the previous pain clinics,” says Valerie. “My son is bed-bound quadriplegic, only travels in a wheelchair and can barely talk or eat from trigeminal neuralgia pain. His health is extremely fragile, and he will surely die if he has to stop his pain medication abruptly. That happened once before and he went to the ER in an ambulance having seizures.”
Armstrong has only a few days left of his last prescriptions.
“We need help and we need it now. He only has a few days supply of his pills left and then I’m sure his body will give out from withdrawals,” says Valerie. “My son had never taken any kind of pain medication before going to the National Pain Institute six and a half years ago and now he is physically dependent on them. I have begged and pleaded with them to take him back and even called their corporate headquarters to no avail.”
There is often little recourse for patients like Chris Armstrong. Malpractice and patient abandonment laws vary from state to state, but discharging a patient is generally considered legal, as long as it isn’t discriminatory.
Florida’s Board of Medicine says a “health care practitioner can terminate a patient relationship at any time, but the practitioner may not abandon a patient” and should provide “continuity of care” until a patient can find a new doctor. To fulfill that requirement, the Florida Medical Association recommends that patients be given adequate notice in writing, be provided with medical care for at least 30 days, and be offered assistance in locating another practitioner – which Armstrong’s previous doctors did.
“There not a lot of strength in the law here,” says Diane Hoffman, a professor of health law at the University of Maryland Carey School of Law. “That makes it very challenging for chronic pain patients. And for physicians, they are trying to find the right place to be. Physicians are very risk averse in terms of the law.”
If patients have a complaint about a doctor, Hoffman says they should contact their state medical board or their state’s consumer protection office.