Elite Pharmaceuticals Inc (ELTP)

[WeeZuhl]

the prescribing habits of internists are different than pain specialists

Yes, this is an issue that I think about occasionally. Specifically… Who will manage chronic pain meds in the future?

PCP’s have typically shied away from this duty, for multiple reasons. First, it can be a real pain to manage chronic pain. In my state, there are no 90 day scripts, no refills, and no faxes or phone orders. Only 30 days at a time, printed on special paper, hand-signed, picked up in person by the patient who must show a picture ID. It may not sound like a big deal, but it doesn’t take many patients on narcotics for it to become logistically difficult and burdensome. Second, there is an issue of government oversight, or fear of it. All narcotic scripts are tracked in a state database. I can look up any patient and see what narcotic prescriptions that patient has received and from whom. Likewise, the Attorney General’s office can look up any doctor and see what they’re prescribing and how it compares to their peers. More narcotic prescriptions could result in more attention from state authorities. Third, nobody likes to play the fool. Most experienced docs have a finely-tuned BullS### Detector, but due diligence requires that they constantly asses the possibility that their narcotic prescriptions are being misused or diverted for abusive purposes. And finally, PCP’s have not been enthusiastic about managing chronic pain because they haven’t had to. Pain management doctors have been glad to make their living evaluating pain and managing it with whatever medications and procedures are most appropriate.

But things seem to be changing. Pain management doctors are just as susceptible (more?) to burnout as any other specialty. One longtime pain management doctor in my town recently took early retirement by blasting his brains onto the back wall of his office, and another doc just closed up shop one day. Imagine the chaos this caused for their opioid-dependent patients (and their PCP’s and E.D. docs!). The pain management docs are busy; it can take months for a new patient to get in, and a lot of these guys are not interested in writing scripts anymore. They want to be doing procedures-- epidurals and nerve blocks, etc.—which pay much higher reimbursements than an office visit alone. If no procedure is needed, then no thank you. And then there is, in my mind, the biggest issue— "insurance shuffling" by employers and the state. One of my patients recently changed insurance companies and could no longer see his regular pain management doctor. No pain management docs in town took his new insurance, and it took my staff a week to find the only doctor in the next town who took it and then months to get an appointment.

At some point, whether they like it or not, PCP’s will be doing a lot more of the chronic pain management than they have in the past. And as they start writing more and more opioid scripts, they will alleviate their concerns about safety, diversion, and oversight by choosing to prescribe abuse-deterrent formulations.