B. Moore's letter to Attorney General AshcroftBenjamin R. Moore DO
PO Box 7253
Myrtle Beach, SC 29572
Dear Mr. Ashcroft
I have been doing locum tenens work for about 7 years (after residency) and most of it was either in an urgent care setting or family practice. I have never had any difficulty with any medical board or DEA. That is until I worked at a chronic pain center in Myrtle Beach, SC. I was brought to work there by Med-Pro, a locum tenens agency, who assured me the doctor I was working for had a good reputation.
Since I had done a residency in neurology and had attended many CME's that included the recent trends in chronic nonmalignant pain and the use of long-term opioids, I felt comfortable prescribing them in the setting of a "chronic pain" clinic. As a matter of fact, without exception, the speakers at these CME's who spoke on the subject chronic nonmalignant pain were all proponents of long acting oxycodone (oxycontin) as the ideal medication because it was non-abusable and considered safe! Anyhow I reviewed the literature, looked at the 1999 policy set by the SC Board of Medical Examiners, and compared it to the clinic's protocol used at the clinic. It seemed to be above board and included all the elements included in the Medical Board's policy.
The DEA agents in South Carolina, however, unbeknownst to me at the time, don't recognize the Medical Board's authority or policy on the subject according to ******, lead investigator. I found this only after speaking with her over the phone. Her opinion was that only terminal cancer patients should be prescribed opiate medications. This of course flies in the face of DEA public testimony found at www.medsch.wisc.edu/painpolicy . I tried to find out what specifically if anything she found wrong with the practice. She told me that opiates were only for "terminal cancer" patients. Other than her uninformed opinion, she would not tell me anything, she said ask an attorney. I did and he said what I was doing was proper and was done in accordance with the State Board's policy.
Of all the doctors that ever worked in that clinic, I was the most conservative with respect to prescribing opiates. The only schedule II medication I ever prescribed was Oxycontin, because it was considered safe and virtually non-abusable according to its maker Purdue Pharma. I routinely did urine drug screens and therapeutic opiate blood levels (to rule out diversion). I terminated over 200 patients personally over the previous year for suspected diversion or doctor shopping. I did not tolerate being used by addicts, and made it clear to my patients that they had better be legitimate.
Over previous years I'd seen pain management specialists speak at numerous CME meetings throughout the country on the subject of opioids and its proper place in the setting of chronic non-malignant pain relief if all else failed. In the majority of our patients, "all else failed". On initial workups if the patient didn't bring adequate records or didn't agree to a trial of conservative non-opiate therapy, I didn't continue to see them as a patient.
Recently, because of the continuing news stories about oxycontin diversion and abuse, I decided to stop prescribing it altogether. I let local physicians and pharmacists know of my decision and asked that it be passed on to the DEA. I decided to refer patients to local pain specialists of good repute.
However, despite the fact that I followed the protocol approved by the SC Board of Medical Examiners and the Federation of State Medical Boards, [a]nd despite the fact that I decided to stop prescribing any Schedule II medications, within two weeks of my decision, (while either discontinuing oxycontin, or weaning it from the clinic's patients) DEA agents marched into the office unannounced and served me with a suspension. Since I was the only doctor left practicing in the clinic after DEA forced 4 physicians out on an improper address issue, patients were left with no help to wean them off medications and/or no pain specialist to continue therapy.
Prior to working in chronic pain management I never prescribed any controlled substance on a chronic or regular basis. Not in a family practice, urgent care, or neurology practice. I have never had difficulty saying "no to patients demanding opiate medication for their pain. I practiced very conservatively. The only reason I employed opiate medication and anxiolytics on a regular basis at Comprehensive Care and Pain Management was because this was a chronic pain management center. This was not a family practice, an urgent care or a neurologist's office. In the setting of pain management within the appropriate parameters, these medications were life restoring to a great many people. I was told by the legal profession that what I was doing at the clinic was legal and proper. The numerous lectures I attended during CME meetings on the subject of chronic non-malignant pain re-enforced the belief that my practice was proper. I was also re-assured by information gleaned from the American Pain Society's, the Journal of the American Medical Association's recent article on opiate use for non-malignant pain. I read and re-read the SC State Board of Medical Examiners policy, which was directly adopted from the Federation of State Medical Boards. To further re-assure myself I contacted my alma mater at UNC in Chapel Hill where I had done training in pain management. They also used opioids in the setting of chronic nonmalignant pain. So I felt assured that there should be no repercussions as long as I followed the state's pain management protocol.
In regards to Comprehensive Care and Pain Management Center the DEA chose to ignore anything that was done right. The only medical opinions they were interested in were those of local addiction specialists. Those specialists locally held quite the opposite view of the use of opiates and anxiolytics in the chronic nonmalignant pain. They see tolerance and dependence as addiction. They don't see anxiolytics as appropriate in combination with opiate medication. Even in the organized "house of medicine" these two groups may vary widely in their opinions on the subject of pain management and chemical dependency. (See Vol. 279 No. 1, January 7, 1998, Letters to the editor). For more information on the subject of chronic pain management reference Portenoy RK. Opioid therapy for chronic nonmalignant pain: clinician's perspective. Journal of Law, Medicine & Ethics. 1996, 24:296-309. Available at 188.8.131.52/research/mayday_jlme/24.4g.html and Schneider JP. Management of chronic non-cancer pain: a guide to appropriate use of opioids Journal of Care Management. August 1998. Available at www.jenniferschneider.com/articles/opiods.html. Add to these the recent rules by the 4
Joint Commission requiring doctors to treat pain and we have a no win situation.
In the end I am convinced that my medical records will bear out the truth. The truth being that I meticulously adhered to a standard pain management protocol and it is that protocol that is part and partial of the Federation of State Medical Boards and that of the state of South Carolina. I did not act as a "pill mill" and I plan to have my DEA return to an unrestricted status. When I do. I will no longer treat pain in the chronic setting, unless it is with only non-scheduled adjunctive medications. In the future those patients needing more treatment will be referred elsewhere. Practicing in this murky, ethical quagmire is certainly not worth the risk of having the heavy hand of governmental regulatory agencies (such as the DEA) second-guessing my medical decisions.
The last time I heard from the DEA or the clinic, lead investigating DEA agents ****** and ****** were taking trophy pictures of each other outside the clinic next to the sign that read "clinic closed by DEA"!
At my last count 11 physicians in Myrtle Beach have had restrictions placed on their DEA in the month of June 2001.
Dr. Benjamin Moore