A Health Care Crisis in Arkansas
A Series of News Stories Health Care Crisis in Arkansas
Chronic Pain & Pain Management Crisis in Arkansas Continues
Part I
By Pat Ivey
Blytheville Courier News
What has been called by some physicians a crisis in medical care has been working its way across the state, and is inching its way into Northeast Arkansas.
Over the past two years, dozens of doctors practicing an accepted medical discipline called chronic pain management have lost their practices and their licenses to practice a medical discipline that is legally allowed in Arkansas.
Pain Management utilizes a combination of intervention or injection treatments, prescription narcotics, diet and other measures to form an overall treatment for patients who experience chronic pain from a variety of conditions. These conditions include cancer and cancer treatment, continuing complications from surgery, endometriosis and other obstetric disorders, and certain autoimmune and connective tissue disorders.
Hardest hit so far has been Northwest Arkansas. In Fort Smith alone, two medical clinics have been shut down and three doctors, including on nationally know pain management specialist and instructor, have lost their licenses to practice. A fourth physician closed his practice when he was notified to appear before the Arkansas State Medical Board, and is currently awaiting that hearing. All of these physicians say they are victims of an effort by the Medical Board to stop the practice of chronic pain management in Arkansas.
One of the doctors to lose both his practice and his license to practice medicine was Dr. Robert Kale, a double board-certified physician in pain management and anesthesiology. Kale's license was suspended Aug. 8, forcing him to close his Medical Pain Management Clinic in Fort Smith. Kale is a member of five different speakers bureaus across the country, and lectures nationwide on proper procedures for prescribing narcotics for chronic pain patients and properly documenting that treatment.
Following the suspending of his license, Kale said he sent copies of the patient records used by the Medical Board to suspend his license to Dr. Barry Cole, director of the American Academy of Pain Management. Cole reviewed the patient records, and informed Kale his practices meet the requirements for standards set in the area of pain management, and recognized nationwide.
"He said I am only guilty of practicing good medicine," Kale said.
Both Cole and representatives of the National Pain Foundation have expressed concerns to Kale about what they call the "lack of education and understanding and the punitive action of the state medical board, and the chilling effect those actions are having on pain management in the State of Arkansas," Kale added. Kale said the Medical Board chairman, Dr. W. Ray Jouett, has publicly stated most chronic pain patients are, in essence, drug abusers who are using chronic pain physicians and clinics to feed their habits.
Kale, however, said this is not the case. Recent studies have shown, he said, that abuse "is not the rule, it is the rarity". Dr. Terry Brackman, also of Fort Smith, has also had his license to prescribe controlled substances, or DEA license, suspended. In addition to eliminating his ability to prescribe pain, diet and anti-depressant medication to his patients, the loss of his DEA license has resulted in the loss of his hospital privileges.
Brackman said the problem has taken two years to surface as a state-wide problem because the board picks a handful of physicians from broad areas of the state each time it holds a hearing for the purpose of disciplining doctors who practice pain management. When only one doctor is affected over a period of several months, it does not generate much media attention, and the general public is not aware of the problem.
"The next thing you know, you have four or more doctors in your area affected, so physicians never get organized against something like this. It just keeps going on and on and on." Brackman said currently, fifty percent of the doctors in the Fort Smith area who practice pain management in some way have been disciplined by the Medical Board for those practices. Brackman said like most of his colleagues, when he was called before the Medical Board over one year ago, he was not worried about the outcome of that first hearing because he know he was following the national standard of pain treatment with his patients.
However, he said he came to realize during that hearing the medical board is not following the standard of care for chronic pain in making their decisions.
"The Arkansas board is forcing us to malpractice with our chronic pain patients," he said. "They are getting away with this only because they are dealing with chronic pain patients. Our patients are the ones that are paying for this."
The Rev. Dr. Ronald V. Myers Sr., of Fort Smith, who has also lost his DEA license and had his practicing license suspended, said Arkansas is in a medical state of crisis because patients who are struggling with chronic pain can't get appropriate medication. He said many are forced to drive great distances to seek medical treatment in surrounding states.
Myers has combined forces with other physicians and state legislators in an attempt to solve the current problem through the state legislature, a step that has been taken by at least 14 other states to protect physicians practicing pain management from punitive actions by their state medical boards.
The practice of pain management is recognized and legal in the state of Arkansas according to state medical practice policy. Arkansas is one of 44 states that have accepted pain management and allow it to be practiced, according to Dr. Aaron M. Gilson, Ph.D. Gilson is chief policy researcher and assistant director of the University of Wisconsin, Pain and Policy Studies Group in Madison, and articles and talks on pain management have appeared in the Journal of the American Medical Association.
According to Gilson, of those 44 states, only 24 have based their operating practice on the Model Guidelines accepted by the American Medical Association, the United States Drug Enforcement Agency and the Federation of State Medical Boards. Arkansas, he said, is not one of these states.
These Model Guidelines encourage the use of controlled substances for pain therapy and provide physicians guidance for controlled substance use. The Model Guidelines also recognize that pain is being under treated, he said, partially because physicians are concerned about investigations by state regulatory agencies and medical boards.
In order to solve this problem, state legislatures in 14 of the 44 states having pain management policies have passed Intractable Pain Acts. These acts give immunity from punitive action by medical boards to physicians who practice pain management under the Model Guidelines.
In order to address the situation in Arkansas, Myers and his group have been working with State Sen-elect Denny Altes, R-Fort Smith, to develop a proposed Intractable Pain Act for this state.
"In Arkansas, the Medical Board has first suspended a physician's license, and then said 'come in and talk to us'. By then the physician is out of business, and their patients have been referred to someone else," Altes said. "It's a bad situation � its like a band of Gestapo trying to rule the world. It's not a nice way to do things."
In addition to working with physicians, Altes said the proposed Intractable Pain legislation is receiving strong support from a surprising sector, the extreme right and Right-to-Life groups.
Altes explained the rate of suicide, including physician assisted suicide, is many time higher among chronic pain sufferers than among all other groups combined. Groups such as James Dodson and his Focus On Family Coalition, the National Right to Life Coalition and the Arkansas Right to Life Coalition have recognized that treating chronic pain sufferers with medication to ease their pain eliminates patient's thoughts of suicide. Because of this, all of these groups have told Altes they will be working with him to help pass the Intractable Pain Act in Arkansas during the upcoming legislative session.
A number of physicians in several areas of Northeast Arkansas have been affected or even censored by the Medical Board for either attempting to relieve the pain of their chronic pain patients, or for planning programs or clinics that might have resembled chronic pain clinics. These interviews, however, were conducted off the record and could not be included in this article because of the physicians' fear of retribution by the medical board.
State Sen. Steve Bryles, D-Blytheville, has been in contact with many of these physicians or their attorneys, as well as Altes, and is currently gathering information on the situation with chronic pain treatment in Arkansas.
"We need to do everything that we can to keep our doctors in rural areas," Bryles said. "We don't need them to be overly encumbered with confusing guidelines as to what is acceptable and what is not."
While most doctors are taking great pains to escape the attention of the state medical board, however, Hale has vowed to pursue every avenue possible to change the current situation for all physicians, from specialists to general practitioners, who want to provide adequate treatment for their chronic pain patients.
"I told them (the Medical Board) they could keep my license," Hale said. "I'm coming after them."
The Medical Board was contacted, but declined comment on the situation.
For more information on the chronic pain management issue, or to express your concerns about the proposed legislation, call:
State Sen. elect Denny Altes at (479) 646-8922;
State Sen. Steve Bryles at (870)762-1365;
Dr. Ronald V. Myers at (479) 783-3661;
or visit the Arkansas Pain Coalition web site at http://www.arpaincoalition.com
Part II
Chronic Pain & Pain Management Crisis in Arkansas Continues
By Pat Ivey
Blytheville Courier News
An unidentified patient who has been suffering from excruciating arthritis pain for years lies face down on a table under a fluoroscope. Dr. Calin Savu, a pain management specialist, inserts needles into her neck, about 1 millimeter from specific nerve endings. He is aided by an X-ray image on screens mounted directly in front of the patient.
A die is ejected from the needles to ensure proper placement of the needles. The needles are then heated to about 80 degrees for several seconds cauterizing the nerve endings and eliminating the pain.
Savu, who operates the Pain Center pain management clinic as an outpatient clinic of St. Bernards Medical Center in Jonesboro, said the majority of his patients come to him after years of suffering without receiving any explanation of the cause of that suffering.
"It is probably the most challenging field in medicine," he said. "You deal with patients who have been suffering for a long time, have been seen by numerous physicians, have been given different or no explanation for their pain and are frustrated by the failure of the medical system to find the solution to the problem."
The discipline of pain management has only recently come into its own, and Savu said many physicians are not familiar enough with the causes of pain to diagnose or treat patients suffering from chronic pain.
"Many people think they are kooks or drug seekers," he said.
While some forms of chronic pain, such as some types of headaches, cannot be treated with anything except drug therapy, Savu said recent advances in the field have resulted in high-tech solutions to some of the most common causes of chronic pain, such as the cauterization of nerve endings in arthritis patients.
"We can't do anything about arthritis, but we can prevent the pain signals from reaching the brain. It's an unpleasant procedure, but there is no other way we can treat this problem."
Another solution is pulsating radio-frequency treatment, which can create an electromagnetic field to prevent nerve signals from being transmitted to the brain. Savu said about 85 percent of the patients coming to his clinic for the first time have no diagnosis to explain their chronic pain. After the testing procedures are completed, only about 15 percent have not been diagnosed. These patients, he said, usually do not have nerve, joint or bone damage and can usually be assisted by using physical therapy to retrain muscles.
Savu, who is from Bucharest, Rumania, graduated from the Institute of Medicine and Pharmacy in Bucharest. He received his internal medicine training in Morristown, N.J., at an affiliate of Columbia University in New York, and completed his anesthesiology requirements at Albert Einstein College of Medicine in New York. His specialty is anesthesiology, with a sub- specialty in pain management.
Savu said he went into pain management at the request of fellow physicians because of the large number of patients suffering from relentless and under-treated pain.
Pain management, he explained, is a multi-disciplinary approach that touches on internal medicine, neurology, anesthesiology and rehabilitation medicine and deals with identifying pain sources and providing long-term treatment solutions.
Solutions involve a combination of medication, injections, physical rehabilitations methods and, if necessary, surgery.
Some of the most common sources of chronic pain Savu treats are back pain; pain resulting from the affects of traumatic injury; degenerative conditions and those caused by advancing age, wear and tear; shingles-related pain; headaches; and cancer-related pain.
Patients must be referred to the Pain Center by their family physician or specialist.
"Their primary care provider can provide us with valuable information about their condition, so we don't have to repeat examinations which have been done in the past," he explained.
On their first visit, patients can expect a discussion with the nursing staff and physician, which basically involves developing a patient history and brief psychological assessment.
The psychological assessment is important, he explained, because more than 80 percent of chronic pain suffers suffer from some form of anxiety and depression. These disorders can actually prevent pain management treatments from being successful.
Once these steps are taken, a treatment plan will be developed and explained in simple language to the patient. This will include a possible explanation for the pain, any need for further study or investigation, and the initial treatment plan which may be changed as test results are received
On the second visit, treatment officially begins. That treatment will be adjusted according to the results of frequent reassessments depending upon the patient's response to therapy.
The Pain Center is offering the most state-of-the-art treatments currently available for chronic pain sufferers, Savu said, including nerve blocks, cauterization and radio-frequency treatment, and implantable devises such as intra-spinal pumps to deliver continuous medication and spinal stimulators.
"Sometimes complete pain relief is impossible," he said. "Even in those cases, a significant decrease in the pain level, along with an improved ability to function, will make a big difference in the quality of life. The bottom line is, no matter how severe or prolonged the suffering, there is hope for a better life."
Any physician wishing more information about the Pain Center may call the clinic at (870) 972-4360.
Part III
Chronic Pain & Pain Management Crisis in Arkansas Continues
By Pat Ivey
Blytheville Courier News
A bill that would protect physicians who prescribe pain medicine for patients experiencing chronic pain has survived two readings in the state senate and has been sent to the Senate Public Health, Welfare and Labor Committee.
However, it's author says he might pull the bill if the Arkansas Medical Board rewrites current medical regulations to include proper pain management practices.
The bill, which is subtitled "An Act to Improve The Treatment of Chronic Intractable Pain," reinforces the existing state medical practice code, which allows for the practice of pain management in Arkansas.
The bill also does several other things. It states that physicians should view pain management as a regular part of their medical practice for all patients with chronic intractable pain, and they should do so by prescribing doses of controlled pain medications in large enough, regular doses to properly manage that pain. The bill states a physician shall not be subject to disciplinary actions by the Arkansas State Medical Board solely for prescribing controlled drugs for the relief of chronic intractable pain.
And, the bill requires the establishment of a Pain Management Review Committee to made up of five members who are board certified pain management specialists, appointed from a list provided by the Arkansas Pain Society.
The Review Committee will work with the Arkansas pain Society to develop guidelines for investigations of complaints regarding conduct in violation of the law, and all investigations by the Medical Board into the practice of pain management will be conducted by the Review Committee.
Further, the bill prohibits hospitals and health care facilities from forbidding or restricting the use of controlled drugs for persons diagnosed and treated by a physician for chronic intractable pain if the drugs are prescribed or administered by a physician having staff privileges at that hospital or health care facility.
The bill was written and is being sponsored by Sen. Denny Altes, R-Fort Smith, in response to requests for his help from both physicians in his district who have had their prescribing license or their license to practice suspended or revoked by the Arkansas Medical Board for practicing pain management, and from patients who cannot now receive treatment for their chronic pain conditions because of actions by the Arkansas Medical Board.
In an earlier interview, Altes explained why he was submitting the Intractable Pain Bill.
"In Arkansas, the Medical Board has first suspended a physician's license, and then said 'come in and talk to us'. By then the physician is out of business, and their patients have been referred to someone else," Altes said. "It's a bad situation � its like a band of Gestapo trying to rule the world. It's not a nice way to do things."
Altes said he was approached soon after his bill, was sent to committee on February 11 by Bill Trice, attorney for the Medical Board, and asked if he would consider pulling the bill if the Medical Board rewrote state medical law to mirror his bill.
"They want to regulate themselves," Altes said. "I put a little pressure on them. They are trying to figure a way out of this."
Altes said the regulations suggested by the Medical Board would have to be acceptable to him before he would pull SB 265. One thing he will insist upon he said, is a committee of pain management specialists to oversee regulation of pain management in the state, and decide what procedures must be followed by physicians practicing pain management in Arkansas.
However, Altes said he has not been given any regulations yet, and he only plans to wait about two more weeks before presenting the bill in committee. Altes said his bill has the support of the Governors office, Arkansas Right to Live and the American Medical Association, as well as physicians statewide.
"I've got the support," Altes said. "I think I can pass this bill."
Pain Management utilizes a combination of intervention or injection treatments, prescription narcotics, diet and other measures to form an overall treatment for patients who experience chronic pain from a variety of conditions. These conditions include cancer and cancer treatment, continuing complications from surgery, endometriosis and other gynecological disorders, and certain auto immune and connective tissue disorders.
The practice of pain management is recognized and legal in the state of Arkansas according to state medical practice policy. Arkansas is one of 44 states that have accepted pain management and allow it to be practiced. However, of those 44 states, only 24 have based their operating practice on the Model Guidelines accepted by the American Medical Association, the United States Drug Enforcement Agency and the Federation of State Medical Boards. Arkansas is not one of these states.
A number of states have passed intractable pain legislation in order to correct this problem, and protect physicians from suspension or penalty for practicing accepted and legal pain management. Texas, Oklahoma and Missouri are a few of the states that already have an intractable pain law. Sen. Jack Critcher, D-Grubbs, chairs the Senate Public Health, Welfare and Labor Committee. He said he has received a number of emails from people urging him to support passage of the bill. None of the emails he has received so far, he said, have been against passage of the bill.
"This is a real problem," Critcher said. "They feel the bill Sen. Altes is carrying will solve this problem."
Altes would like to hear comments from physicians and citizens regarding the Intractable Pain Bill. He can be reached by email at [email protected] us.
Critcher would also like to hear from residents who feel strongly about passage of the intractable pain bill. Critcher can be reached by email at [email protected].
Rep. Kevin Goss, D-Wilson, is a member of the House Public Health, Welfare and Labor Committee, which will receive the bill after it clears the Senate. Goss said he has read the bill and is familiar with it, and at this time sees nothing really wrong with it. He especially likes the fact that there are a number of safeguards placed within the bill, particularly the required formation of an oversight committee made up of pain management specialists."It's easier to police something if you are knowledgeable in the area you are policing," he said.
Goss said he wants to hear arguments on both sides of the issue before making up his mind about the bill.
He encourages his constituents to contact him at [email protected] with their views about the Intractable Pain Bill.
Part IV
Chronic Pain & Pain Management Crisis in Arkansas Continues
By Pat Ivey
Blytheville Courier News
A local doctor will soon be able to practice her trade fully again following a second decision by the Arkansas Medical Board. According to Dr. Judith Butler, the Medical Board notified her last week she was approved to reapply for her Drug Enforcement Agency license, a license which allows physicians to prescribe certain types of medications and have hospital privileges.
Butler was called before the board early in December to face charges that included continuing juvenile patients on medication routinely prescribed for Attention Deficit Hyperactivity Disorder without seeking a second opinion each time a refill was prescribed, and prescribing diet pills.
Butler explained when she came to Arkansas from Nebraska after 17 years of practicing medicine there, she was not aware the laws governing these medications were different in Arkansas. When she was notified by the board she was not in compliance with Arkansas law, she took steps to change her practices and came into compliance.
That original communication was two years ago, and Butler said even though she has since come into compliance with those regulations, she was investigated and disciplined for that oversight. Butler's attorney, Diane Mackey of Little Rock, said the Medical Board gave no reason for the decision, but that is not uncommon. "They don't have to give a reason," she said.
Mackey said the decision to approve Butler's DEA status came following a petition filed by Butler stating the she had complied with all the Medical Board's requirements, and cited the hardship being endured by her patients because of the suspension.
"This has been emotionally and physically devastating," Butler said. "My entire life has been dedicated to study and labor directed toward caring for the sick and the poor. My staff and I were so convinced we were in line with national standards of care with 'good medicine', we really did not expect any penalty no matter who reviewed our work.
"An unfortunate complication of the board's action was the loss of admitting privileges to the hospital, so continuity of care, something extremely valuable in patients with complex health problems, was interrupted," Butler continued. "We are all relieved by the board's recommendation to allow a return to full prescribing."
While charges against Butler did not specifically mention pain management, which she practices in her clinic, Butler believes that was a major issue in the actions taken against her by the Medical Board. Butler said the issues of chronic pain management, of who should be the policeman for the problems of street drugs and how best to merge the two, remains to be solved, but that job should not be the responsibility of physicians.
"I don't believe the doctor can be the law officer of record," she said. "If he is not the patients' advocate, who will be? We have always taken reasonable measures to assure appropriate safeguards to control abuse or misuse of medications and to avoid diversion (illegal selling) of prescriptions given for the intention of relieving pain and suffering."
For more information on the chronic pain management issue, or to express your concerns about the proposed legislation, call
State Sen. elect Denny Altes at (479) 646-8922;
State Sen. Steve Bryles at (870)762-1365;
Dr. Ronald V. Myers at (479) 783-3661;
or visit the Arkansas Pain Coalition web site at www.arpaincoalition.com
