Daniel Kantor, MD, is the President of the Florida Society of Neurology and Medical Director of Neurologique in Ponte Vedra, Florida. He is a Board Member of the Duval County Medical Society and was recently placed on the Florida Medical Association’s Council on Legislation.
Neurologists should not treat migraines. Sound unreasonable? Not according to pain doctors speaking at the Florida Medical Association Board of Governors meeting this past October. Florida is widely known as a state suffering from an epidemic of “pill mills,” where addicts flock to in order to be prescribed and to purchase opiates. In response to the daily reports of opiate-related deaths, the Florida legislature passed laws restricting the practice of pain management. On the surface this seems like a noncontroversial and laudable legislative move; however, the unintended consequences caused by the new law may prove to be the largest hurdle facing neurologists in Florida, and eventually in the rest of the country.
The Devil Is in the Details
S.B. 2272, which went into effect on October 1, 2010, places needed restrictions on pain management clinics. The problem lies in the definition of pain management clinics—a medical practice that advertises “in any medium for any type of pain management services.” Thus, cardiologists who advertise for “cardiac chest pain management,” or gynecologists who offer treatment for vulvodynia, or neurologists who offer migraine or neuropathic pain treatment are all considered to be running pain management clinics. Aside from the registration fee, yearly inspections by the Department of Health, and potential for daily $5,000 fines, violators will be charged with a third-degree felony and their patients’ charts may be seized without a subpoena or written authorization.
In response to this, Florida neurologists are changing the names of their practices, covering up signs, taking down Websites, and refusing to see patients with any type of pain complaints. The law also lumps Schedule V medications with the other controlled substances, and many neurologists have chosen to stop prescribing Lyrica® (pregabalin). By July 1, 2012, physicians who haven’t completed an Accreditation Council for Graduate Medical Education (ACGME)-accredited pain residency or fellowship (note that headache fellowships are not accredited by the ACGME but by the United Council for Neurologic Subspecialties) will no longer be allowed to advertise their services, and this represents dire consequences for patient safety.
Patients will be inundated with advertising by chiropractic neurologists regarding their expertise in migraine management. Since neurologists will no longer be recognized as headache specialists, unsuspecting patients will be drawn to chiropractors who will refer these patients to pain doctors for narcotics, while completely ignoring potential red flags and missing signs of dangerous headaches, such as temporal arteritis or brain tumors.
The new law has taken the focus away from the one mechanism with the potential to actually curb the dangers of prescription drug abuse—a Prescription Drug Monitoring Program (PDMP). Such a program was originally set to take effect on December 1, but its implementation is mired in legal challenges by companies bidding for the statewide contract. Additionally, the PDMP has received no state funding, and its enforcement remains unclear.
Neurologists Slighted
At the recent Florida Medical Association Board of Governors weekend, pain doctors argued that since some neurologists send them migraine patients for opiate management, the pain anesthesiologists are better equipped than neurologists to manage headache patients in general. Additionally, these pain doctors felt that they were better qualified to treat neuropathy pain and that neurologists should stick to stroke, epilepsy, movement disorders, and multiple sclerosis. It seems clear that neurologists need to initiate a public and professional awareness campaign to highlight the diversity and depth of our training.
The Florida Society of Neurology (FSN) is taking a leading role in safeguarding patient safety and in protecting the ability of Florida neurologists to practice medicine. The FSN has signed on to an amicus brief for a constitutional challenge to the new law, is working hand in hand with the Florida Medical Association to petition the Department of Health and Board of Medicine for declaratory statements to clarify what constitutes legal advertising, and is working with the Governor’s Office of Drug Control. FSN press releases, media appearances (http://www.youtube.com/watch?v=6aWSeFtd50w), and discussions with the Florida Surgeon General and Director of the Division of Medical Quality Assurance at the Department of Health are helping to raise awareness regarding the dangerous unintended consequences of the Pill Mills law. The FSN is working diligently to fix this law and to help prevent the spread of similar laws to other states.