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Pill Mills vs. Pain Management in Flagler: The Difference From the Doctors’ Perspective

| December 11, 2010

The legit kind. (© FlaglerLive)

Note: Flagler County Sheriff Don Fleming’s effort to impose a moratorium on the opening of new pain management clinics in Flagler County, in an effort to stave off the spread of “pill mills” from South Florida, brought some awareness to the pill mill problem–as does the arrest of Fleming’s own son for possession of a controlled substance–but also highlighted another problem: the confusion, in many people’s perceptions, of pill mills with legitimate pain management practices. A local physician explains the difference.

By Kavita Sharma

The need for public awareness about pain “clinics” or “pill mills” has become evident, as the Drug Enforcement Agency (DEA) and the Florida Department of Health have recently ended long-time sting operations with arrests of physicians who abused their privilege in order to carelessly contribute to a epidemic in our state and our country – the misuse and abuse of prescription drugs. While we in the medical community breathed a sigh of relief upon hearing this news, we also braced ourselves for the impact of collateral damage. The atmosphere has become one of distrust and fear and has made the legitimate practice of pain management extremely difficult.

Patients who come to our practice often scratch their heads when we advise them, “We will be working on reducing your pain without the use of medications, but rather through a combination of interventional treatment and physical or occupational therapy.” It seems that even patients have come to expect so little from their physician that when an actual physical examination is conducted and pathology is explained to them, they often tell us that they previously thought they were “just going to get a prescription for something to kill the pain.” Often, colleagues in the medical community are even surprised to hear that Pain Management can encompass diagnostics, interventions, physical modalities, and therapy, while decreasing the focus on medication management.

The American Board of Pain Medicine defines the specialty as “a discipline within the field of medicine that is concerned with the prevention of pain, and the evaluation, treatment, and rehabilitation of persons in pain.” In order to become trained in the field of pain management, physicians must complete full specialty training in either anesthesiology, physical medicine & rehabilitation (PM&R), neurology, or psychiatry.

Kavita Sharma (© FlaglerLive)

After completing one of these residencies (requiring four years beyond graduation from medical school), the physician then completes additional fellowship training in the sub-specialized field of pain management for 1-2 years. Often, this additional training involves learning interventional spine procedures and non-surgical peripheral joint care as well as management of medication for both acute and chronic care. By the time physicians have completed these minimum of five years of post-medical school training, they are trained in certainly more than just signing a prescription.

The question is:  how does one identify a real pain management specialist as opposed to a “pill mill” or “pain clinic”?

There are a few giveaways. For instance, in a real practice, it is just that – a practice, with board certified physicians in pain management. Walk-in patients are not accepted. Rather all patients needing to be seen are required to make an appointment and have a referral from their primary care physician, so that we know why we are seeing the patient. Care begins with a history taking and physical examination and a review of the imaging studies and explanation of the findings, as well as an outline of treatment options and treatment planning between the patient and the doctor. Most specialty practices have also stayed current by using an Electronic Medical Records system, or EMR/EHR.

The Live Commentary

By contrast, in many “pain clinics,” walk-ins are the only method of intake, the office is understaffed, no referral is required, and little or no examination or work-up is done. Also, a legitimate practice will only accept patients that have health insurance, whereas most “pill mills” will see patients for cash payments without any health insurance. This difference is a giveaway, since most insurance companies will actually require that physicians who provide care to their patients meet certain standards and be board certified in the specialty. Otherwise, care and visits will not be authorized.

Often, we find as pain management practitioners that we ourselves “police” the patients we see, requiring them to sign narcotic contracts which outline the rules of receiving narcotic pain medications if this is necessary. “Pill mills” may not require such contracts between the practice and the patient, since these enforce mandatory randomized urine drug screening, reporting of pharmacies used, and call for patients who misuse medications or violate contracts to be discharged (fired) from the practice altogether.

Another important factor is reputation itself. The practice of medicine for any specialist  is and always will be to an extent a “business” practice. Like any other type of business, practices have employees and staff and render care to the best of their abilities, knowing all the while that their livelihood and the ability to keep those people employed depends on the reputation earned and kept. As such, a legitimate practice or physician will hold a certain standing within the medical community and the local region. Therefore, if others around you or your own doctors have known a pain management group or physician to be of good quality, this is a reliable factor.  Specialists in most private office settings will also often have hospital privileges and will render both outpatient and inpatient care. This is important to look for since it tells us about the physicians as enthusiasts within the medical community, as opposed to doctors that become isolated.

The closing down of many “pill mills” from South Florida all the way up the eastern corridor has resulted in “patients” willing to drive a long way to continue receiving prescriptions from other doctors. We have made what I would call a nearly heroic effort as doctors to police these people ourselves, although I would never under-credit the work that I’m certain local, state, and federal law enforcement are doing to this end. After all, patients as well as physicians were arrested in some cases.

Our practice itself is made up of four physicians, all board certified in pain management, as well as carrying other board certifications. We will continue to serve our communities in Volusia and Flagler counties, and to battle the social issues tied to misuse and abuse of prescription pain medication.  A senior partner remains active on committees at the state level dedicated to these causes, and all partners continue to educate the patients and physician colleagues.

Kavita Sharma, who is board certified in in physical medicine and rehabilitation, is one of four physicians at PRC Associates, a pain management practice at Palm Coast’s Town Center and four other locations. The other physicians are Vinod K. Malik, Youssef Guergues and Tse Chung Lee.

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7 Responses for “Pill Mills vs. Pain Management in Flagler: The Difference From the Doctors’ Perspective”

  1. mariodigir says:

    This is all a bunch of bull. The only issue is the Sheriffs son is a drug addict. So, he’s takes a personal family issue and attempts to negatively impact the lives of people who require pain medication on a daily basis to function. There are no viable “alternatives” to pain medication, and to suggest that there are, is malpractice of the highest level. Doctors need to have ALL treatment options, including pain medication, available to them, without fear of the “pill police” knocking on their doors, fear of reprisal, or fear of being considered a pill pusher. I am outraged by the systematic government control over our daily lives. Stay out of our personal medical affairs, as … it is none of your business! Pain medication is an absolute necessity for the treatment of pain for a multitude of medical conditions and must not be interfered with by any outside entity. Prescribing pain medication is a confidential and personal decision between the doctor and patient. We have more than enough controls in place already. Enough of this insanity!

  2. mariodigir says:

    So, after reading about the arrest of Fleming’s son, I’m confused: Is his son an addict?, does he have a drug problem?, why were the police following him?, why did they pull him over?, is this issue actually being created by the crack down on being able to get necessary prescribed medication?, what is the real motivation behind the Sheriff creating all this hysteria about supposed pill mills?

    The amount and type of drugs that he was caught with is not very impressive. So, what is this really all about?

  3. scott says:

    The good doctor states that a patient must have insurance as a prerequisite for legitimacy? What does having insurance coverage have to do with legitimacy? There are millions of Americans who don’t have insurance and they are in pain. Does the absense of insurance make them drug addicts? I have read about this before and will never understand how politicians and now doctors can make such stupid statements.

  4. Dr. Sharma says:

    You must have insurance, because of the treatment options that these specialists offer. If someone happens to go into a doctor’s office and has no insurance, offers cash, and then expects medications, but can’t quite afford the actual expensive treatment options, it’s a problem. Doctors are trained to treat patients, order tests that we need, offer procedures that will help. This is not the atmosphere for negotiating prices for those things, etc. We don’t want a “cash for drugs” situation or anything near it because it does not leave a paper trail for pharmacies, insurance companies, and the DEA, so tracking where and when patients have filled medications, or if they have filled prescription from multiple doctors (doctor shopping) is not possible when they have used cash. This measure therefore MUST be taken. Legitimacy is not the issue. In medicine, as much as we wish we could, we can’t make “guarantees” for outcomes. Patient expectations for outcomes can become a little swelled when someone pays cash, because now they see themselves as a “customer” and not as a patient. Fortunately, still many patients want to be actively involved and responsible in their care decisions and we love these patients! They actually want to tackle their health in all the ways that they can, rather than placing it entirely in the hands of a physician that they see once every 3-6 months. In procedural fields like Interventional Spine, interventional Cardiology, Gastroenterology, and all surgical fields, the challenge of taking care of patients is great enough. We do our best and we have each spent anywhere from 12-17 years learning how to do this (without pay during those years, by the way – only accruing debt for the cost of an education, college, med school, internship, residency, then fellowship). Yes – often politicians do make silly statements about the practice of medicine, or healthcare. But if you’re hearing something from someone who actually put in the years and sweat, it may be for a good reason. Unfortunately, we’re all hard at work, and not spending our time lobbying for ourselves. We probably should. I know we wish we had the time.

    • Anonymous says:

      If you are so worried about really helping people with pain. Why don’t you give up one day a month to treat people for free. All your worried about is the money. I tried your way and I am in more pain now, atleast I can funtion with the meds.

  5. Teri says:

    So the only thing PRC pain management wants to do is epidural injections. It does NOT want to fix the problem but hide it with nerve blocks….. great………………….and this is speaking from my EXPERIENCE, not conjecture. I am sure they can bill more for injections then meds….

  6. A Family Practitioner says:

    Dr. Sharma,

    I’m sorry to strongly disagree with your statement “Also, a legitimate practice will only accept patients that have health insurance, whereas most “pill mills” will see patients for cash payments without any health insurance.” Are you implying that if you do not have insurance you can’t have pain and you are not a legitimate patient?

    Also, you said, “You must have insurance, because of the treatment options that these specialists offer.”

    What about the thousands of chronic pain sufferers that do not have health insurance? What do you suggest? Oh, I know, nothing, because you won’t see them to even make a suggestion.

    What would you suggest for a 45 years old gentleman without health insurance who has a lumbar spinal stenosis with neurogenic claudication when walking 50 feet, who has lumbar DDD, DJD, HNP and suffers with chronic pain?

    Your suggestion will probably be a series of injections, or perhaps straight to surgery. But, guess what, he cannot afford either option. Would you tell the patient “suffer with pain?”

    I’m making this comment 2 and a half years after your comment. Things have changed some, but your opinion that a patient without insurance or a doctor who would accept cash for a visit as not legitimate is rather elitist and disconnected from reality.

    A family practitioner in Volusia county

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