Pain treatment

State Regulators Punish Doctor for Cutting a Pain Patient's Opioid Dose and Dropping Him After He Became Suicidal

The decision by the New Hampshire Board of Medicine suggests state officials are beginning to recognize the harm caused by the crackdown on pain pills.

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A New Hampshire doctor recently got into trouble with state regulators because of the way he treated a pain patient. But in a refreshing twist that suggests state officials are beginning to recognize the harm caused by restricting access to pain medication, the New Hampshire Board of Medicine reprimanded and fined the doctor not for prescribing opioids but for refusing to do so.

In May, the New Hampshire Union Leader reports, Joshua Greenspan, a Portsmouth physician certified in pain management and anesthesiology, signed a settlement agreement with the state medical board that included a reprimand, a $1,000 fine, and "at least 12 hours of education in prescribing opioids for pain management and in pain management record-keeping." The settlement stems from a June 2018 complaint in which a patient reported that Greenspan, "after treating him for years and prescribing the same dosages of pain medication, suddenly reduced his medications, which led to increased pain and anxiety, and suicidal ideations."

According to the settlement agreement that Greenspan signed, the patient "had suffered from chronic pain for many years, stemming from a number of different sources, including back and leg pain from a fall, testicular pain after a surgery, neck and back pain from a motor vehicle accident, and chest and shoulder pain following coronary bypass surgery." A previous doctor had prescribed the patient two 80-milligram tablets of OxyContin, an extended-release formulation of oxycodone, plus four 30-milligram tablets of immediate-release oxycodone, per day.

Although Greenspan initially continued those prescriptions, in April 2018 he informed the patient that the Centers for Medicare and Medicaid Services (CMS) had imposed a cap on opioid prescriptions of 90 morphine milligram equivalents (MME) per day. Based on the conversion factor used by CMS, the patient was receiving more than four times that amount: 420 MME per day.

But as the medical board noted, that 90-MME rule, which did not take effect until the beginning of this year, is not a hard ceiling. Instead the CME requires pharmacists to consult with prescribing doctors before filling prescriptions that total 90 MME or more per day. Greenspan's confusion is understandable, however, since CME initially proposed a stricter limit, from which it retreated in response to strong objections from doctors and patients.

The 90-MME threshold is based on 2016 prescribing guidelines from the U.S. Centers for Disease Control and Prevention (CDC) that have been widely misinterpreted as requiring dose reductions for patients who already exceed that arbitrary cutoff, even if they have been functioning well on those doses for years. That perception has led to involuntary dose reductions and patient abandonment across the country. The CDC belatedly repudiated that misunderstanding of its advice in a statement and a journal article last April, three years after issuing the guidelines and one year after Greenspan erroneously told his patient that the federal government was demanding dose reductions.

After Greenspan cut the patient's daily dose by 40 milligrams (60 MME), the patient found that his pain was no longer well-controlled. According to the settlement agreement, the patient repeatedly complained about unrelieved pain and on one occasion visited a hospital because he was having a "tough emotional time." Greenspan "made no referrals or recommendations regarding these issues, but instead reduced the patient's dosage by another 20 mgs." The Union Leader describes what happened next:

Later that year, the patient failed a pill count and was admitted to a hospital for threatening suicide.

That's when the doctor told the patient he was no longer comfortable prescribing opioids for him and would no longer treat him. He also "reported his concerns about (the patient's) well-being" to the local police department and the man's primary care doctor, according to the settlement. He also sent a prescription for an opioid withdrawal drug to the patient's pharmacy.

The board found that Greenspan's handling of the case violated ethical standards of professional conduct.

That conclusion highlights how concerns about the "opioid crisis," reinforced by real or perceived demands from the government, have perverted the doctor-patient relationship, making physicians agents of the war on drugs, which is inconsistent with their professional duties. The medical board's decision suggests that New Hampshire regulators understand the dangers of those conflicting priorities. Perhaps not coincidentally, New Hampshire is also fighting the Drug Enforcement Administration's demands for warrantless access to prescription records.

Bill Murphy, a local pain treatment activist, told the Union Leader the resolution of the complaint against Greenspan "sends the right message to physicians in New Hampshire," who need to understand that "the guidelines are just that—guidelines—and not hard-and-fast rules." At the same time, Murphy expressed sympathy for doctors who feel pressured to reduce opioid prescriptions and worry that they could lose their licenses, livelihoods, and even their liberty if they are identified as outliers. "I think in the end they do want to help people," he said. "They feel like they're caught between a rock and a hard place."

[This post has been updated with additional details from the settlement agreement.]

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  1. How is this good? Other than highlighting how capricious governments are, all it does is put the doctor in an impossible situation. Whose side does he take so the other can pummel him?

    1. I think a doctor should know the text of prescription regulations and also the consequences of changes to opioid dosages. I understand the possibility of overhead pressure but it seems careless to reduce a long-term dosage of oxycodone and then claim that he’s just following orders.

      1. Too bad he’s not a cop.

        1. Sure sounds like one

      2. I understand the possibility of overhead pressure

        I don’t think you do.

        When the CDC issues best practices guidelines, failure to follow their “suggestions” can result in massive lawsuits and jail time and loss of a medical license you’ve got a big chunk of your life and two shitloads of money invested in.

        Reason has done at least a couple of articles about this – the CDC sent out a “Dear Colleague” letter and then acted all surprised that their “advice” on what you should do if you know what’s good for you was taken as an order by just about every damn doctor in the country. This isn’t like your boss suggesting you short-weight a customer just a little bit, this is like your boss suggesting you short-weight a customer just a little bit while he holds a gun to your head.

        1. Well that is pretty frightening. My reply might have been more concerned with the moral responsibility of being a doctor rather than the practical implications. It may be idealistic to call this man a coward but I will in the same way I would to a cop or a tax collector (although that might be a false comparison).

          1. This man (Dr. Greenspan) is actually very brave for practicing the type of medicine he does. He’s in the mold of Hurwitz (check out Jacob’s other articles on him) and they’ve finally found a way to cut him down. I feel for him and his many other patients.

      3. He reduced the dose to 360 MME well above guidelines and prescribed an opiate withdrawal drug. This doc did not start the patient on such a high dose to begin with.

        The problem started when the patient failed a pill count and had suicidal ideation. At that point the patient is non compliant and has a psychiatric issue which the doc cannot treat. He notified the primary care and the police.

        The only problem I can possibly see is this “That’s when the doctor told the patient he was no longer comfortable prescribing opioids for him and would no longer treat him”

        So if he totally abandoned the patient that is not ethical. If he had told the patient that he should find another doctor, made a referral and continued treating him in the interval that would be OK.

        Most people and the article are missing the point. It is good medical practice to try and reduce the dose with someone on this high of an opiate dose. He did not drop the patient to 90 MME all of a sudden.

        This is why most docs do not want to deal with this at all.

        1. ” It is good medical practice to try and reduce the dose with someone on this high of an opiate dose.”

          No it’s not. Not unless they were found to be abusing their meds, selling them, or experiencing intolerable side effects. It’s good legal practice, for fear of DEA. It’s abhorrent medical practice directly contrary to the health and best interests of the patient. And indeed, caused suicidal ideation here (and plenty of other actual suicides). This doctor *created* the situation, in a way well known to create such situations.

          1. I do not agree. The website here will only allow one link so will not let me post anything like a review of the literature.

            Long term sequela of high dose opioids in someone with chronic pain are well documented. It is not to say that they are not useful but there are big downsides. It is very difficult to manage once the patient has been on the therapy for years.

            These patients are already at high risk for intentional or accidental overdose. Opioids act on the central nervous system including higher regions of the brain in profound ways. It is not an optimal way to control pain and restore function to the individual in the long run.

            Pain management docs try hard to have alternatives.

            We can’t tell from this article what happened here exactly. The suicidal ideation may have been caused by the very high dose dependence, not by the effort of the doc to reduce the dose.

            Literature recommends that in taking on a patient like this a clear plan needs to be developed. A written treatment plan signed by the patient is a good idea and has been advocated.

            Don’t know why the board dinged this doc. He is not just a drug dealer. I suggested a reason.

            1. Absolutely true. Every pain doctor’s goal is to try to move the patient away from narcotics. They transform pain into intractable chronic pain. I definitely know doctor’s that have been successful with this and the patients are VERY grateful.

              As far as the suicidality, that could be a ruse. Many chronic opioid abusers are very manipulative (borderline personality disorder). This definitely could have been a factor in the doctor’s decision to “fire” the patient. There are strict rules to dismiss a patient from your practice including making sure that short term prescriptions are taken care of. He obviously followed these rules or the lawsuit surely would have mentioned this.

    2. I’ve actually been to Dr. Greenspan (I asked, no relation to the charlatan). I found him because he’s one of the last Drs left willing to take on new pain patients. He does clearly state his rules, yet was very upfront about saying that he’s willing to work with you ignorant you’re honest with him. I suspect (yet obviously have no idea the true circumstances here) that the patient gave him reason to be wary. When this fellow was off on his pill count, what else was he supposed to do? As mentioned in other comments, Drs are in a hell of pickle. Had this man told him that he couldn’t handle the dose reduction before the pill count, I have a great feeling that the Dr would’ve worked with him.
      I don’t blame this man, I blame stupid gov’t edict here. Greenspan is a good man. I’m happy that he hasn’t lost his license.

      1. AS long as you’re upfront with him*

    3. Agreed. The problem here is the FUCKING GOVERNMENT.
      We allow women to “murder” their babies under the mantra, “My body, my right”… why doesn’t this idea apply to drugs? Shouldn’t a person be allowed to put into their own body anything they desire? A gram of oxycontin? A gallon of beer? 5 grams of methamphetamine? If they die as a result, whose problem is that? Incinerate the body and use it to fertilize crops.

  2. Good to see but I feel for this doc because I am sure the DEA will be knocking on his door soon because he is now following the New Hampshire’s regs instead of their policy goals.

  3. Classic “damned if you do, damned if you don’t”!

    Thanks Government Almighty! May I have another?!

  4. Another example of the nanny state trying to control the doctor-patient relationship.
    Since when do politicians and bureaucrats make good doctors?

  5. >>> the “opioid crisis,” … perverted the doctor-patient relationship

    ACA?

  6. To avoid whipsawing doctors between competing jurisdictions, each threatening punishment, why not have a constitutional amendment reserving to the states the power to regulate the practice of medicine? The amendment could read as follows:

    “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

    1. I mean, I bet the doc would rather be sanctioned by the state medical board than to be paraded in shackles in front of the news cameras while a federal prosecutors announces a crackdown on a “pill mill.”

      1. That’s, like, a dead constitution & a suicide pact.

  7. The Rev: “Open wide, clingers, here comes some federal universal health care coming straight at you!”

  8. We have to have a prescription system to restrict access to drugs because a no one knows better than a patient’s doctor how drugs should be used by that patient. No one except state bureaucrats, but that goes without saying.

  9. The decision by the New Hampshire Board of Medicine suggests state officials are beginning to recognize the harm caused by the crackdown on pain pills.

    Oh, sure, they recognize the harm, but they ain’t accepting a single speck of culpability for it. Doctors are responsible for prescribing the exact right amount of pain medication, not too much, not too little. And if the Venn diagram of “too much” and “too little” has a 50% overlap, that’s not the state officials’ fault.

  10. “at least 12 hours of education in prescribing opioids for pain management and in pain management record-keeping.”

    Oh, FFS! Make it 48 hours, taught by our opioid-specialist contractors and using our proprietary record-management software.

  11. Sounds like the doctor either willfully or mistakenly misinterpreted the 90 MME “limit” here – either would be a failing on his part, so a fine against the doctor is appropriate. However the state should also be filing suit against the CDC and any other federal agencies that were involved in issuing the guidelines in the first place.

  12. “…Greenspan’s confusion is understandable,…”

    No, it isn’t. The man is supposed to be a professional; we expect professionals to read and understand regulations relating to their professions.
    I’m sure the issue was covered widely both on-line and in print pubs within his specialty, and he was either too lazy or too stupid to understand.
    He should have been punished far more than a puny $1K fine and time spent on a golf course during some medical convention.

    1. I’m sure that, unlike the FYTW clause in the Constitution, the invisible ink used to indicate which CMS suggestions are just suggestions and which suggestions are really “suggestions” is much more apparent.

    2. I can imagine the press release issued by some federal prosecutor after a doctor took your advice:

      “Today we arrested Dr. Jones, a ‘pill mill’ operator who supplied the needs of opioid addicts, who even overprescribed opioids for a patient who had given every indication of mental instability. Thinking only of profit, Dr. Jones continued to supply this patient’s addiction, prescribing FOUR TIMES the government-recommended dosage. This dangerous pill-mill operator will be sent to the federal penitentiary or my name isn’t Preet Bhahara.”

  13. “the guidelines are just that—guidelines—and not hard-and-fast rules.”

    This is how it starts.

    1. “the guidelines are just that—guidelines—and not hard-and-fast rules.”

      That was the CDC’s intent in issuing the guidelines.

      The problem is, the CDC doesn’t control the DEA (agency charged with enforcing the controlled substances act). If the DEA decides to treat the CDC guidelines as a hard and fast rule, the CDC can’t change that. And doctors who ignore the DEA’s position will end up spending time in Federal custody.

  14. When the state board issues a “guideline” every doc knows what that means.

    This doctor is a specialist in pain management. He could lose his whole practice if accused of overprescribing.

    No wonder most doctors don’t want anything to do with it.

    Most patents are now referred to these specialists. This is not just because of fear of the state. Truth is most primary care docs do not know very much about pain management and have little interest in it. Refilling prescriptions for chronic pain is not what they signed up for.

  15. 28th amendment:
    Congress shall pass no law, nor the federal government create or promulgate any regulation affecting in any way the interaction of a United States citizen with any medical practitioner.

  16. When you first accept that the state as the right to regulate a profession or trade, you then accept that it has the right to do it in an arbitrary and capricious manner – because you have granted government administrators the power to impose their personal will and preferences on those they regulate regardless of their competence in the field they are regulating.

  17. That was a HECK of a huge does reduction for someone who was obviously in tremendous pain and just trying to make it thru the day.
    To be suddenly cut off and then, thrown into the nuthouse for thinking about killing himself from the pain is happening all across this country. The process is excruciating.
    I suspect many doc, pharmacist and certainly, the DEA are not concerned with their patients “well-being” nor the harm this kind of cut-off cause at all. People can die of this.
    It’s all gone way overboard and, as with all other drug wars, is making some people a lot of money as our medical system crashes around us.
    Pain control is about the only thing doctors can do for most patients and, contrary to the propaganda is NOT the cause of this scam “opiod epidemic” Street fentanyl and heroin is.

    Chronic pain patients do get accustomed to their dosage, but have always been closely supervised and don’t “get high”.
    Even the WHO says what the USA is doing is “cruel and unusual” and they can make up statistics for about whatever they want to.
    I hope this expands to the rest of the country. I am now abandoned by my pain doc and have no recourse, that I can find to this punishment of being in pain for 30 years.

    Just another rightwing scam to attack us all, while they label us “addicts”

  18. The decision by the New Hampshire Board of Medicine suggests state officials are beginning to recognize the harm caused by the crackdown on pain pills.

    One would hope…

    But I think you’d be wrong to do so.

    I would be willing to bet that this is a one-off based entirely on the outcome and complaint, not on a loosening of the restrictions dictated by the moral panic.

    I know that they are still so paranoid that when my wife broke her leg a couple of weeks ago, the attending in the ER only gave her 5 minimum strength hydrocodone pills to get through the 3 days until she could be seen in the orthopedics office. At one pill every 4-6 hours as needed for pain…. well, you do the math.

    The opiod addiction panic is still on the upswing, with no obvious end in sight.

  19. I vividly recall the particular patient [of refractory trigeminal neuralgia], sitting in bed waiting for the operation. He was crouched in profound suffering, almost immobile, afraid of triggering further pain. Two days after the operation, when Lima and I visited on rounds, he was a different person. He looked relaxed, like anyone else, and was happily absorbed in a game of cards with a companion in his hospital room. Lima asked him about the pain. The man looked up and said cheerfully: “Oh, the pains are the same, but I feel fine now, thank you.”

    Clearly, what the operation seemed to have done, then, was abolish the emotional reaction that is part of what we call pain. It had ended the man’s suffering. His facial expression, his voice, and his deportment were those one associates with pleasant states, not pain. But the operation seemed to have done little to the image of local alteration in the body region supplied by the trigeminal nerve, and that is why the patient stated that the pains were the same. While the brain could no longer engender suffering, it was still making “images of pain,” that is, processing normally the somatosensory mapping of a pain landscape.

    In addition to what it may tell us about the mechanisms of pain, this example reveals the separation between the image of an entity (the state of biological tissue which equals a pain image) and the image of a body state which qualifies the entity image by dint of juxtaposition in time.

    — António R. Damásio Descartes’ Error: Emotion, Reason, and the Human Brain (paragraph breaks added)

    1. Thanks I found the book. Going to read that.

    2. I had read some of the books by Oliver Sacks. Seems in a similar vein.

  20. […] seems to be further discouraging such prescriptions by making physicians worry, even more than they already do, that their good-faith assessments of patients’ needs will expose them to scrutiny that could […]

  21. […] seems to be further discouraging such prescriptions by making physicians worry, even more than they already do, that their good-faith assessments of patients’ needs will expose them to scrutiny that could […]

  22. […] seems to be further discouraging such prescriptions by making physicians worry, even more than they already do, that their good-faith assessments of patients’ needs will expose them to scrutiny that could […]

  23. […] seems to be further discouraging such prescriptions by making physicians worry, even more than they already do, that their good-faith assessments of patients’ needs will expose them to scrutiny that could […]

  24. […] seems to be further discouraging such prescriptions by making physicians worry, even more than they already do, that their good-faith assessments of patients’ needs will expose them to scrutiny that could […]

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