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Some prominent Arkansas pain doctors are asserting that the practice of responsible pain management in the state has a bad case of shingles — as in too many unqualified doctors hanging theirs out as pain specialists in the hopes of making easy money. Another reform advocate calls that a bunch of hooey but says the bigger problem is that too few physicians are willing to give patients the time-intensive, low-reimbursing continual care they need for chronic pain, opting instead for expensive procedures that may actually cause harm. Either way, both sides seem to agree that unless changes are made, the under- or mistreatment of pain will continue to be a chronic problem for too many Arkansans.

Which changes need to be made, however, depends on who you ask.
Dr. Laurence Ault has been a practicing anesthesiologist and pain specialist in central Arkansas since 1985. What started out as a small field of practice exploded a few years ago, and he said that specializing in pain is now “so fashionable, everybody and their brother is getting into it, thinking it’s easy.”

Many of the procedures and injections that interventional pain specialists typically provide patients are pretty lucrative. Ault said well intentioned or not, too many generalists and physicians from other specialties think they can provide treatments just as competently as a board-certified pain specialist can. Most of the time they can’t, and the patients suffer from, at best, pain that doesn’t respond to the treatment, and, at worst, complications that can include permanent injury, paralysis and death.

“Anyone who’s completed medical school and done a year of internship can call themselves a pain specialist and start treating patients,” Ault said, “but hanging out their shingle doesn’t mean they have any training or credentials at all in pain medicine. Arkansas doesn’t require it, but the patients don’t know that.”

He said that about half of those practicing pain management in his area are not even board-eligible, as they have not passed their basic medical boards.
Board certification in pain medicine or pain management is available from a number of professional organizations, but most of these certifications aren’t recognized by the organization that matters most, the American Board of Medical Specialties (ABMS). For ABMS, however, pain medicine isn’t a specialty unto itself; it exists only as a sub-specialty of anesthesia, neurology, physical medicine and rehabilitation, or psychiatry. In Arkansas, only 25 physicians out of the dozens of physicians practicing interventional pain management or prescribing narcotic medicines hold this recognized additional certification in pain medicine.

Ault points to this as a problem. “We get people hanging out their shingles wanting to do the (pain) blocks, basically for the money,” he said. “A number of them will not take over patients for pain medicine or prescribe pain medicine or do anything like that. Then, on the other end, you get a number of people putting out their shingles as pain medicine doctors as one of their many specialties, and they’re placing patients on these massive quantities of multiple narcotic pain medicines, muscle relaxants, sleep aids and more all at once and not adequately addressing the primary problem.”

He said patients are becoming dependent on these medications and still having significant amounts of pain because they’re not being seen by someone trained in the nuances of pain medicine. “Being a neurosurgeon, for example, doesn’t actually mean you’re good with injections,” Ault said. “That’s a micro procedure, and they’re trained in macro procedures.”

The executive director of the Arkansas chapter of the American Society for Interventional Pain Physicians (ASIPP) agrees and is actively working to increase the credentialing standards for the specialty. Dr. John Swicegood of Advanced Interventional Pain and Diagnostics of Western Arkansas in Fort Smith recently met with Arkansas Blue Cross and Blue Shield about changing the pain specialist credentials necessary for reimbursement. He said Blue Cross was very responsive to the problem and has opted to use the strict credentialing requirements that board-certified pain specialists such as himself and organizations such as ASIPP have asked of their members.

ASIPP is one of the bodies that offers a thorough credentialing process including education, hands-on testing and sit-down testing, but that is not recognized by the ABMS.

Swicegood said that in his practice, he gets to work early and leaves late and is able to see only 16 to 18 patients a day. “But there are doctors who may just line up 30 pain patients and say all you need is an epidural, regardless of their conditions,” he said. “They know the pain codes, and they’ll just assign a code that will pass through Medicare or the insurance company.”

This results in the over-utilization of pain codes. Because Medicare operates on a zero-sum budget, all things have to fit within that budget. When people over-utilize anything in any field it takes away from those who really need it.
“Anyone working to try to gain these credentials, it’s just a validation of their commitment to this particular field or sub-specialty. Whereas, many unscrupulous individuals will try to obscure or maybe bend their credentials,” he said. “I’m not trying to say anything bad about anyone, but we need better standards. Maybe they’re a retired orthopedic specialist or a semi-retired neurosurgeon trying to adapt those skills to interventional pain medicine, but it doesn’t quite translate, and that’s a big problem.”

But Dr. Robert Kale adamantly disagrees with Ault’s and Swicegood’s concerns. Kale is a pain specialist and reform advocate who relocated his former Fort Smith pain clinic a few miles away in Roland, Okla., after an Arkansas State Medical Board investigation into his prescribing methods effectively ended his practice (although he was later cleared of the over-prescribing charges).

He concurs that more education in pain management is desperately needed in the profession as a whole, but said, “It’s garbage. You cannot rationally limit the responsible practice of pain management to only people who have the added certification.”

Kale, who holds certifications from boards not recognized by ABMS, said this issue comes up from time to time, but it’s never really about quality of care. Rather, he said, it’s about protecting practices’ revenue streams from competition.

He said the physicians who have the added certification always say it’s about increasing the standards and enhancing patient care, but that it’s used by insurance companies to limit access to medical care. “When they say you can only have ‘this’ done by ‘these’ doctors, it limits patients,” he said. “Many patients won’t be able to get in to see those few doctors.”

Because pain medicine is only a sub-specialty, not its own recognized board specialty, Kale sees the issue as even more hypocritical. He compared it to the other sub-specialties available to board-certified anesthesiologists.

“Most anesthesiologists in the state don’t have added certification in neurosurgery, even though it’s available, and yet many anesthesiologists are doing specialized neurosurgery anesthesia. Likewise, the majority of cardiovascular anesthesia provided is provided by anesthesiologists without added certification in cardio-thoracic. And I certainly would say the majority of pediatrics is the same. That doesn’t mean they didn’t receive any training, just that it is the accepted standard to provide specialty anesthesia without the extra certification.”

A bigger concern Kale has is what he terms the over-utilization of procedure codes by everyone, board-certified pain experts included. Kale is a passionate believer in the benefits of opiate therapies, acupuncture, and other rehabilitative modalities and a fierce opponent of most epidurals and other injections when used to treat chronic pain.

“They need to be driving medications instead of useless, possibly harmful procedures,” Kale said, quoting a 2006 study from the Cochrane Report on Evidence-Based Treatment of Chronic Low-Back Pain that lists some of the most popular interventional procedures in the “Not Beneficial, Probably Harmful” category of efficacy. He said it doesn’t make much difference how well a procedure is done; for chronic pain patients, the procedures have little to no benefit to anyone but the doctors collecting the checks.

Swicegood and Kale both insist that there is a lot of misinformation about the hazards of prescribing opioids like Oxycontin, but they once again disagree on what that misinformation is.

Kale says that most physicians have enormous fear of over prescribing—either legitimate fear of coming under regulatory scrutiny or fear based on misinformation about the addictive qualities of these drugs. They can be highly addictive under the right circumstances, but he said most patients who take them, even those who become physically dependent on them, do not develop addictions. There is no ceiling on opiate dosages, and with proper titration to effect and rigorous monitoring, Kale said many patients can obtain enough relief from debilitating pain to return to some level of normal functioning, even on extremely high dosages.

This requires a substantial time commitment to each patient, though, for very little reimbursement, in contrast to the nice profits procedures bring. Plus, because the Drug Enforcement Agency (DEA) and Medical Board are concerned about diversion — a greatly overblown problem, in his opinion — physicians have even less incentive to “stick their neck out” for their patients who they worry may be users trying to get prescriptions to sell on the street. Because of his personal experience with the dropped over-prescription charges and his belief that he was unduly harassed for his liberal prescribing practices, Kale has a highly cynical take on the oversight bodies.

Swicegood, on the other hand, insists that the misinformation out there is that legitimate, responsible physicians have anything to fear from these bodies. He was a member of the Arkansas State Medical Board’s pain care subcommittee for three years and in June traveled with ASIPP leaders to Washington, D.C., to have open discussions with the DEA and administrator Karen Tandy. He was impressed by the competence, forthrightness and good intentions of those involved.

“The Medical Board wants people in pain to get treated,” Swicegood said. “And the DEA really wants physicians to treat patients in pain.”

He added, “They don’t count tablets. They’re not looking out for what drug you’re writing. They just want it to be a bona fide patient-physician relationship. If physicians just show that they conduct a thoughtful and thorough history, a careful patient exam and make an effort to diagnose correctly and to rationally and responsibly prescribe controlled substances, I just don’t think there would be a great deal of trouble. I don’t think they need to fear treating pain patients.”

He remains very worried, however, about any physicians who attempt interventional pain procedures without proper training and certification.
Ault said that medicine and interventional procedures are only some of the treatments in a legitimate pain specialist’s toolbox. “I don’t avoid treating people with narcotics, that’s one of the mainstays a physician has,” he said. “But you have to treat them appropriately. Narcotics aren’t the only answer. You’ve got physical therapy, interventional techniques, medications other than narcotics, psychological treatment and it’s really a multi-modal approach. You can’t treat patients with just narcotics, just like you can’t treat pain patients with just physical therapy or with just injections and nerve blocks. There’s got to be a multidisciplinary treatment plan.”

All the physicians interviewed agreed that too many patients are subjected to the maximum number of blocks or other procedures and then promptly fired as patients when the lucrative treatment options run out. They are still in crippling, excruciating pain all day long, but they don’t have a doctor, and they must start over again in the search for someone who can help them return to normal functioning.

“I would be happy if these doctors who are using the patients up with procedures, board-certified as well as the rest of them, would just take care of them afterwards with medicines and the other treatments available,” Kale said. “Anything less is malpractice.”



August 2007

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