Dope addicts & the dealers in white coats

A lot of dope addicts get their fix from a most reliable source -- licensed physicians.

What happens is, you go to the doctor, tell him its hurts, get a prescription, pay an office fee, then go the pharmacy. If necessary, you go to a bunch of doctors and a bunch of pharmacies.

Painkillers are what we're talking about. All sizes and shapes and colors of painkillers.

'Course, the public's conception of a dope dealer is not the guy or gal in the white coat. It's the guy in the hoodie standing down on the street corner. But you got to watch for the white coats.

That's what the Texas Board of Medical Examiners (TBME) is supposed to do. Keep watch on the guys and gals in the white coats.

On Dec. 10, the Disciplinary Review Committee of the TBME recommended that "Chapter 170, Authority of the Physician to Prescribe for the Treatment of Pain" be repealed, with the proposed changes to be published on Dec. 31 in the Texas Register.

The Purpose

The changes, according to the Dec. 31 issue of the publication, are intended "to protect the public and to provide physicians with a higher level of comfort in the use of dangerous drugs and controlled substances in the treatment of pain..."

In explaining its purpose, doctors were assured they "should not fear disciplinary action from the board for prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. The board will consider prescribing, ordering, dispensing or administering controlled substances for pain to be for a legitimate medical purpose if based on sound clinical judgment. All such prescribing must be based on clear documentation of unrelieved pain."


"The board will judge the validity of the physician's treatment of the patient based on available documentation, rather than solely on the quantity and duration of medication administration."

It added: "Allegation of inappropriate pain management will be evaluated on an individual basis. The board will not take disciplinary action against a physician for not adhering strictly to this policy when contemporaneous medical records document reasonable cause for deviation. The physician's conduct will be evaluated to a great extent by the documentation of pain treatment, recognizing that some types of pain cannot be completely relieved, and by taking into account whether the drug used is appropriate for the diagnosis, as well as improvement in function when such is possible."

(fyi: The words in italics and bold-face are italicized and bold-faced by me.)

The New Guidelines

The new guidelines that were to be put in place would require doctors:

* to evaluate the patient and "document the presence of one or more recognized medical indications for the use of a dangerous drug or controlled substance."

* to make a written treatment plan.

* to discuss the risks and benefits of pain medication, including the "potential for dependence, addiction, escalation, tolerance, and withdrawal precautions; and
potential for impairment of judgment and/or motor skills."

* to monitor the progress of the patient; "If the patient's progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities."

* to "consider" an agreement with patients with a history of drug abuse that entails: "written agreement between the physician and the patient outlining patient responsibilities, including: urine/serum medication levels screening when requested; number and frequency of all prescription refills; one physician prescribing controlled substances and/or dangerous drugs in the treatment of pain; use of one pharmacy for prescriptions, and reasons for which drug therapy may be discontinued (e.g. violation of agreement)."

* to be "be willing" to refer the patient for further treatment; "The management of pain in patients with a history or substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients."

* to keep complete and accurate medical records of everything.

Finally, the changes state: "A decision by a physician not to strictly adhere to the provisions of subsection (a) of this section will not solely be grounds for the board to take disciplinary action in regard to the physician. Each case of prescribing for pain will be evaluated on an individual basis. The physician's conduct will be evaluated to a great extent by the treatment outcome, taking into account whether the drugs used are medically and/or pharmacologically recognized to be appropriate for the diagnosis, the patient's individual needs including any improvement in functioning, and recognizing that some types of pain cannot be completely relieved."

The Upshot

So all of this was put on the table in the Dec. 31 issue of the Texas Register.

What happened?

In the last issue of the Texas Register, which came out yesterday, the Texas Board of Medical Examiners announced, without comment, it was withdrawing the proposed repeal of the old pain medication guidelines. Back to the old rules, which it clearly thought were deficient in the first place.

Why?

There's nothing that I can find in the newspapers. The Texas Board of Medical Examiners didn't provide any explanation on its Web site, and didn't call a press conference.

I can only guess what happened.

Some doctors somewhere figured it was all too much paperwork, all too much trouble and might have placed them at too great an exposure to disciplinary measures at the disposal of the Texas Medical Examiner's Board, so they complained to their friendly legislators and/or the TMBE itself. But that's just a guess; I could be wrong.

Bottom line: the candy store is still open.