Dr. Petersohn of Philadelphia

Sirs:

If you are the idealists you aspire to be, GIVE the software to your colleagues for a single nominal fee which reflects the cost of developing the product. Charging a monthly fee is a scummy ploy to regularly extract money playing on the fears of physicians who keep poor records, maintain a dubious standard of opiate prescribing, and routinely use industrial strength controlled substances because they are not fully trained pain docs or because they have realized how much money they can make writing controlled substance medications with little or no medical basis as opposed to the hard work that is legitimate medical practice. These practices are no better than the epidural injection or trigger point patient mills favored by ambulance chasing attorneys. If we succumb to these poor practices, we are little better than used car salespeople or politicians.

Offering single-modality treatment with opiates by prescription to the majority of patients in any practice, even a pain practice, is the modern version of "Tea and sympathy," and a highly suspect strategy employed in desperation to provide a simple (but ineffective and inappropriate) solution to a complex problem because the physician, however well-intentioned, lacks the skills and knowledge to evaluate and resolve the underlying problem. Yes, perfect interventional and rehab solutions do not exist for all problems, but most patients who benefit from erudite professional care.

We all know that opiate outcomes are mediocre overall, seldom resulting in improved patient function over years or allowing return to work, etc. The data simply do not support opiophile practice, yet the opiate industry supports groups, like the American Pain Society and the American Academy of Pain Management, yes, and also the throw-away "journals" which espouse opiate medications and oppose interventional treatment. Hard to trust these organizations, in that interventional treatment is based on clearly defined principles of anatomy, neurology, physiology, neurosurgery and orthopedics which have superior outcomes with robust literature support.

As an organization, you will likely go broke defending the practices of the many physicians who charge $100-120 per patient office visit for writing Rx opiates without REAL medical indications. I have seen at least three physicians taken out of practice in my county in the past year and all of them truly deserved to be forcibly retired from their suspect practices, yet more of these fellows remain in their offices, writing Rx's and watching their cash registers ring. These docs should be closed down and the DEA and State Police should be watching these practices closely. While you espouse a noble cause, we must see how noble you are by your standards and your actions or disappointingly, if you are just another group of get-rich-quick schemers. I hope you are the former.

Jeffrey D. Petersohn, M.D
Adjunct Associate Professor
Department of Anesthesiology
Drexel University School of Medicine
Philadelphia, PA
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Dear Dr. Petersohn:

I have practiced the medical management of chronic pain for almost 20 years now. I have a paper in draft for submission for peer review that reports the results of following a universal sample of 204 patients (every consecutive pain patient enrolled in treatment) for ten years. The paper reports the regimen, the doses and schedules, the pain levels, the functionality, adverse consequences (including aberrant behaviors), range of motion and patient and family reports on outcome.

The medical management of pain is bi-phasic. The first phase, after review of history, initial evaluation, affirmation or determination of diagnoses and construction of a plan of treatment, is titration to effective pain control. In conformity with all Standards of Care, dosage and schedule of opioids is entirely individualized, with no restrictions by pre-conceived notions of "maximum" doses.

The second phase is long-term , almost totally stable (pathology does increase in some cases, requiring occasional [but relatively few] adjustments in medication. Virtually every patient in the study achieved remarkable improvements in pain levels, functionality, range of motion (often more than 20"), family confirmation of improvement, with VERY few incidents of aberrance. No overdoses occurred. A few patients were terminated for non-compliance, often determined by urine testing for compliance or obvious "red-flag" events.

If you believe that long-term opiate management is rarely successful it is most likely the consequence opiophobic
under-treatment.
Regarding the PPLA, the offer of electronic medical record keeping is not an activity owned by PPLA. It is an outside source through Medical Office Online. I myself pay the monthly fee (from which PPLA receives NO benefit), which I find to be not only very helpful in maintaining my medical records in compliance with the looming EMR requirements under the Health care Reform Act, but also very inexpensive in comparison with on site hardware and software alternatives.

We share with you your disdain for "Pill Mill" pain treatment. But we do not demonize these operations. They are obviously a free-market response to the millions of blue-collar pain patients who are un or under-insured, and for whom $100 a month is a lot of money. The "War" on these clinics is actually a "War" on blue-collar pain patients (see my blog entry on this subject at www.jfshmd.blogspot.com). Relatively few of the hundreds of patients who attend these clinics are criminals. But the authorities, seeking to maintain the anti-drug hysteria that has directed a trillion dollars of funding into their pockets over the last 20 years, have shifted from anti-illicit drugs (a total failure) to prescription drugs, as a self-serving propaganda campaign to continue their gravy train.

I personally also decry the Intervention-mills, where, as Perry Fine mentioned to me recently, "the only requirement for utilizing procedures is an insurance policy." Interventionalism" has become just another money-making scheme, unimpeded by any scientifically defensible outcome data, which strongly requires the construction of Standards of Care and decision-tree criteria, with robust outcome studies.

We have spent five years bringing PPLA to the medical profession, to encourage the legitimate and effective treatment of millions of unnecessarily crippled patients. Opiophobia, and the fear of regulatory catastrophe, stand in the way of that goal. PPLA provides a state of the art Standard of Care and Record-keeping, the services of a panel of pain-management "luminaries" to provide expert consultation and legal defense expertise, highly accomplished legal consultants to guide legal defenses where necessary, inexpensive EMR, and up to $500,000 of legal defense (to prevent the bankrupting of legitimate doctors.) No practitioner-member of PPLA who practices below the Standard of Care will meet the criteria for being defended.

We urge that you join, and if you are so inclined, join our Professional Advisory and Review committee (along with Perry, Sharon Weinstein, Stratton Hill, Steven Simons, Joe Pergolizzi, and ten others.) And I urge you, before you go off on something about which you clearly had done little exploration, to do your homework first.

J.S. Hochman MD