Photo taken today at dawn.
Step therapy is a common practice used by health plans to limit the cost of patients’ medications.
Health plans? Please. These “plans” have nothing to do with health.
With step therapy, patients have to go through a series of steps, taking other medications and failing on them before being allowed to receive the medication originally prescribed by their doctors. These requirements are not dependent on a patient’s medical situation, but rather by cost.
In some cases, patients are forced to fail on numerous medications, some with serious side effects. This practice does not single out one group of patients. Step therapy is applied to treat a wide range of disease and chronic conditions, including cancer, Alzheimer’s disease, autoimmune diseases, diabetes, psoriasis, epilepsy, glaucoma, hemophilia, HIV/AIDs and mental health among others…
First published on June 1, 2014
It is important to clearly address these responsibilities and expectations at the onset of establishing a treating relationship, particularly when the increasingly controversial subject of opiate medications is involved.
Risk Identification and Stratification
Patients should be notified prior to their visit that medications will not be prescribed during their first appointment. The purpose of the initial evaluation is to obtain a thorough history and physical examination to ascertain the most appropriate treatment course. The history should include information relevant to the pain condition, past medical history, and psychiatric functioning. A risk assessment tool for substance abuse should be administered in the event that opioid prescribing will be a part of the treatment plan…
Patients who are categorized as “Low Risk” on the ORT, present a medication history that corresponds with the CURES [PDMP] report, have a UDS result that is consistent with their prescribed medications, and do not have untreated or undertreated mental health issues are considered at low risk for opioid abuse. Prescribing of opioids may be initiated if it is clinically indicated. Before opioids are prescribed, the patient should sign written documents that explain the risks of opioid therapy and the parameters of treatment…
Consistent UDS results, CURES reports, and appropriate responses in the above areas suggest a lack of contraindications for continued opioid use. However, any deviations in the above parameters would result in the patient being recategorized as being “At Risk” and would prompt a switch to the pathway described in the next section.
Patients are considered “At Risk” for opioid abuse due to any combination of the following:
-Moderate- or high-risk result on the ORT
-Medication history that does not correspond to the CURES report
-UDS result that is inconsistent with prescribed medications
-Untreated or undertreated mental health issues
An evaluation by a pain psychologist should be obtained for all at-risk patients to identify the nature and extent to which psychological factors may be influencing the patient’s predicament. An additional consultation with an addiction medicine specialist should be obtained for patients at moderate or high risk based on the ORT, incongruent CURES, or inconsistent UDS results.
Upon completion of the additional evaluations, the information should be integrated to identify whether the patient should be recategorized as low risk or if an active substance abuse disorder is present that necessitates formal addiction treatment…
Reasons to Consider Opioid Cessation
It is critical for prescribing providers to actively monitor patients to ensure that use of opioid therapy remains appropriate. The parameters surrounding the number and type(s) of infractions that would result in medication discontinuation should be specified clearly in the agreement. Once the threshold for discontinuation has been reached, providers should initiate a taper. Contraindications for continued prescribing include (but are not limited to) aberrant behavior, lack of functional improvement, and medical complications…
Lack of Functional Improvement
One of the hallmark differences between acute and chronic pain is the fact that the latter lacks a definitive cure; thus, treatment approaches focus on management of the condition. It can be tempting to focus solely on pain palliation when prescribing medication, but optimal pain management treatment should encompass a wider range of factors, including functional status and emotional well-being. Use of activity diaries (documents in which patients track daily activity), monitoring of work absenteeism due to pain, and obtaining corroborating information from family members may facilitate assessment of functioning…
Opioid Risk Tool (ORT) Assessment Instrument
Reprinted With Permission from Lynn Webster, MD
I took the test and scored in the “high risk” category. In fact, I can’t imagine that too many pain patients would score in the low or moderate risk categories, as you (and your family) would have to be saints (or devout Mormons) to do so. And if you have a large family, then you’ll have a higher risk for family members who have abused drugs or alcohol.
For instance, who doesn’t have a family member that has abused alcohol? And if you’re an older pain patient, who hasn’t abused alcohol in their youth? I know I did — not to the point of addiction, but I did some wild partying in my younger days. Of course, I quit drinking (and partying) a very long time ago. I can’t remember the last time I had any alcohol, including wine. Still, I’d be penalized for stuff that happened over 25 years ago.
And the test appears to discriminate against men, who get a higher score than women if they’ve ever abused alcohol and/or illegal drugs. And if you’re a woman who’s been a victim of preadolescent sexual abuse, you get high marks used against you — but if you’re a man, you get no marks at all.
My high risk score just confirms that if I were to see a pain doctor, I would be denied any kind of treatment that included pain medication. Of course, this test is self-reported by patients, so I could always lie on the questionnaire, as I’m sure many patients do.
Forty cops are in a classroom, watching recent footage of protesters in San Francisco denouncing the police. “Your children are ashamed of you,” a black woman in the video tells a black officer, who looks away. “Coward!” others shout. A young demonstrator walks up to a cop and sticks out his middle finger. A female officer trips, and the demonstrators laugh.
The volume is way up, and the cops in the room are leaning back in their chairs, crossing their arms, getting tense. Jim Glennon steps to the front of the room and stops the video… “Welcome to our world,” Glennon says. “It’s as bad as it’s been since the ’60s and ’70s.”
The officers nod in agreement. At one point, Glennon asks how many of them have been spat on. Most raise their hands.They’re sitting at long tables in a bland room in a facility in Urbana, Ill. A former county nursing home, it’s now occupied by the Illinois Law Enforcement Alarm System, created in 2002 to coordinate statewide responses to terrorism and disasters. The lobby features a mannequin in tactical pants and mirrored sunglasses, a table of books and brochures—among them, Developing the Survival Attitude and Online Predators—and a big-screen TV tuned to Fox News.
Glennon runs Calibre Press, one of the country’s largest private police training companies, and this is the start of a two-day seminar, Street Survival, which has been taught to hundreds of thousands of officers over four decades…
Like many companies in the business, Calibre promotes a “warrior” mentality for police, likening cops to soldiers and focusing on conflict, vigilance, and martial skills…
Glennon’s students are mostly white men in their 20s and 30s, some with firearms strapped to the belts of their cargo pants, joined by a handful of women, black officers, and older men… One student in the class interrupts to say it doesn’t help when the president sympathizes with protesters. “It doesn’t,” Glennon says. “It’s easy to demonize the cops.” He tells them law enforcement ranked as less respected than medicine in a recent Gallup poll—even though, he says, doctors’ mistakes kill 98,000 people a year while police kill 400… (The FBI estimates there are about 400 annual justifiable police homicides. One Washington Post tally found almost that number killed by police in the first five months of this year.)
Before proceeding, Glennon points to a threat in the back of the room: me. “In 35 years, we have not allowed the press to come into a class,” he says. “The reason is because we don’t trust them.” He says he’s letting me observe because many police chiefs are frustrated no one is advocating for them. They’re tired of being portrayed in the media as racists and unaccountable killers and want a more sympathetic depiction. If my article screws them, he tells the class with a smile, “I’ll fly out to Seattle”—where I live—“and kill him.” …
Being drilled to think of everything and everyone as a threat fries my nerves. That evening at my hotel, I press the elevator button and suddenly hear gunfire behind me. It’s the ice machine…
There’s no universal model for police training, with almost 650 police academies around the U.S. and more than 12,000 local departments, according to the Department of Justice. In addition, many agencies provide continuing education offered by their own officers or private companies…
For all the concern about risks, the rate of officers murdered in the line of duty is dropping, according to FBI statistics. In 1984 the 10-year average was 97 a year; as of 2014, it was 51. With some 63 million face-to-face interactions a year between police and the public, a cop’s chances of being murdered are fractions of a percent…
“What’s the only rule in a gunfight?” Glennon says. “Win the gunfight. There are no rules. That’s it, right?”
Kors: Did you ever meet a veteran who called the Crisis Line?
Goosenberg Kent: I did. The New America Foundation was screening our film, and a veteran at the screening told me she called the Crisis Line. She had been sexually assaulted while serving and was struggling with that. She said the Crisis Line saved her. To hear that from a veteran, in person, it was wonderful. She said that after the call, she got herself to a better place and got involved with [the Iraq and Afghanistan Veterans of America].
Kors: It is tough, though, for veterans to get to a place where they’re ready to call and ask for help.
Goosenberg Kent: I think it is. That’s part of the culture that I was hoping to chip away at, this idea that only the weak pick up the phone and ask for help. I remembering reading a series of articles about soldiers being bullied for seeking help, including soldiers at Fort Carson who were actively discouraged from seeking help. That was heartbreaking to me, and when I made this film, those articles very much in my mind. I wanted veterans to see that asking for help is actually a sign of strength. It’s an act of courage, one that doesn’t make you any less of a hero. In fact, it’s the beginning of getting your life back together.
Veterans Crisis Line: 800-273-8255 (Veterans: press 1)
Wounded Warrior Project: 877-832-6997
Caregivers Support Line: 855-260-3274
“You must lose a fly to catch a trout.” George Herbert
“I decided to fly through the air and live in the sunlight and enjoy life as much as I could.” Evel Knievel
“I decided blacks should not have to experience the difficulties I had faced, so I decided to open a flying school and teach other black women to fly.” Bessie Coleman (American Aviator, 1892-1926)
“The air is the only place free from prejudice.” Bessie Coleman
“Let the little fairy in you fly!” Rufus Wainwright
Part of the reason that Unum has considered looking outside itself for new revenue streams is the meandering path the rickety U.S. recovery has taken, top executives said.
“We’ve been successful despite a weak economy and soft financial environment,” Watjen said. “It’s difficult to grow, but it’s not hindering our ability to be a successful company.”
Both Watjen and McKenney, as well as Unum Group Chairman Jon Fossel, said that it will continue to be difficult to do well in the current economic and regulatory environment.
“The economy is recovering slowly in fits and starts, and unemployment is still high,” Fossel said.
Unum, which markets mainly to employers who then offer the plan to individual employees, depends on other companies to hire and retain workers to organically grow its bottom line. The recession made that more difficult, and hiring still hasn’t increased enough to even keep up with population growth.
Additionally, the company has become concerned that lawmakers could perceive the insurer as a health care concern, and be treated accordingly by lawmakers searching for ways to pay for the national health care reforms adopted by Congress last year…
“People need to recognize we’re not a health care company,” he said. “We work with employers to get people back to work, and getting that through Congress is a challenge.”
In fact, Watjen said, companies like Unum actually help people “take responsibility for themselves and their families, and take pressure off the federal programs” in a time of shrinking wages and work forces…
Before authorities caught up with him, Dr. Richard Kaul performed back operations for years in same-day surgery centers around North Jersey, even though he was an anesthesiologist, not a surgeon trained to operate on spines.
Patients went to him to treat their pain, but some described horrifying problems following his operations. A mother of young children told state officials she was left to ride home in agony, unable to walk after surgery that went on for hours. The operation left her feet splayed and her gait unbalanced, she said, and she is in such pain she has to sleep in a recliner rather than in a bed. A blasting supervisor who worked at Ground Zero testified that he lost his job and his professional licenses after the operation left him in such agony he became dependent on painkillers. A policeman said he can no longer stand for more than a few minutes.
They were among 11 patients whose cases were recounted, sometimes in gruesome detail, at an appeals hearing on Kaul’s license, which has been suspended. Expert witnesses testified that the doctor, who practiced at nine locations in North Jersey, performed operations that were unnecessary and implanted spinal screws so poorly in one patient that they caused excruciating damage.
Remarkably, before all this, Kaul had been convicted of negligent manslaughter in England after a patient he had anesthetized died while having a tooth pulled. After his conviction in 2001, he was sentenced to a six-month suspended jail term. The British medical board stripped him of his license, concluding that the “gravity of the offense” was so serious the only recourse was to “erase” Kaul from the registry of doctors.
But that didn’t stop Kaul from moving to New Jersey and establishing a practice treating mostly car accident victims and people with out-of-network coverage in their health insurance plans. His decade here has been marked by misrepresentation, malpractice complaints and allegations of racketeering and insurance fraud.
His is the story of a shrewd physician who exploited licensing rules that allowed him to perform complicated and risky procedures outside his training and who figured out how to skirt the rules of a state with one of the nation’s weakest systems of doctor discipline. It is a system that relies on doctors to be honest when answering questions on official forms about their training, their practices and their pasts…
Kaul lied on his license renewal form when he said there were no criminal charges against him, but the state never checked that. State officials never checked whether, as required, he was affiliated with a hospital or had other permission to operate in his single-operating-room surgery center. They never checked whether he had the required malpractice coverage in case something went wrong.
Even when the state learned of the lies surrounding the death in England, the Board of Medical Examiners allowed him to continue practicing after a six-month suspension.
Furthermore, the state did not restrict Kaul’s practice to anesthesiology He was able to perform surgery because his license, like medical licenses in all states, was a general authorization to practice medicine and not limited to a specialty — a long-standing national licensing norm that may be outdated.
His case raises a disturbing question: How can patients know their doctor is qualified to diagnose and perform the procedures he or she prescribes — particularly in the state’s one-room surgery centers, which are largely unlicensed? …
One man, whose name was withheld by the state at the hearing to protect his privacy, testified that he went in expecting an injection for pain and ended up with hours of surgery to remove a disc and fuse two bones in his spine. Others showed long scars from surgery they’d been told would be “minimally invasive.” They described crippling injuries, intractable pain and the betrayal they felt at the hands of a doctor whose credentials and skills they trusted…
He had come to New York in 1989, following medical school in London, and bounced around three surgical internships — none of which would have given him enough training to operate on spines, the state said — before entering the three-year anesthesiology program. In 1996, the American Board of Anesthesiology gave him a lifetime certification as a specialist. Every two years, even when he was working outside the United States, he renewed his license to practice in New Jersey using a form of mostly yes or no questions…
As Kaul’s criminal trial got under way in London in January 2001, he applied for a medical license in Kansas. The board in that state checked with the British hospital where he had practiced and rejected him outright.
In contrast, he had no such issues in New Jersey. In April, after his conviction, Kaul applied to Hackensack University Medical Center for privileges, and to state authorities for a license to prescribe narcotics. Both were granted…
During this period, Kaul was struggling with drug addiction, he said in a recent interview. He developed a taste for party drugs in New York in the mid-1990s and then became addicted to opioids, which he obtained easily as an anesthesiologist, he said. He said he received help from the British medical board, but relapsed in the United States, where he checked into a monthlong rehabilitation program in 2002. He said he is now clean…
Kaul did not practice in a hospital again. But he was able to find work in a burgeoning field of health care — pain management.
He rotated among a variety of free-standing chiropractic, surgical and pain-treatment centers, which have proliferated in New Jersey, allowing physicians to share in the high out-of-network reimbursements they receive for treating patients and to tap into the state’s generous auto-insurance coverage for personal injury. Several such businesses have been sued by insurance companies alleging overtreatment and fraud…
An anesthesiologist with a similar spine practice in Washington State, Dr. Solomon Kamson, flew in to testify at Kaul’s hearing. He said that Kaul’s board-certification as an anesthesiologist, as well as his surgical training and additional coursework, amply qualified him to perform minimally invasive spine surgery. Kamson has faced his own regulatory issues — his medical license has twice been placed on probation in Washington State, said a spokeswoman for the Washington Department of Health…
How to Help a Grieving Friend: 11 Things to Do When You’re Not Sure What to Do
After visiting the grower’s market on Saturday — and safely storing my mushroom and cheese pizza pies and 6 fresh peaches (for $5) in my car — I went to see how Maxine and Max were getting along.
I’m sorry to report that Max is no longer with us. (Yes, it could’ve been Maxine who got the ax, as I can’t tell the difference between the two. But for the purposes of this story, Max is history.) Although Maxine was very quiet, hardly gobbling at all, she was still in fine form, posing for my camera and ruffling her feathers.
The good news is that everyone on the farm enjoyed fresh roasted turkey for their July 4th celebration.