Pain Center Crisis: How the Healthcare Community Coped

ORLANDO — On the opening day of the annual meeting of the American Academy of Pain Medicine (AAPM), Brett R. Stacey, MD, medical director of the Center for Pain Relief at the University of Washington-Roosevelt, recounted the events that occurred in the summer of 2016 in his home state that led to the closing of the Seattle Pain Center. His presentation titled “I Need a Refill: 8,000 Patients Search for a New Pain Home in a Statewide Response to a Real Medical Crisis,” sought to highlight how the healthcare community reacted to and coped in the aftermath of this event, by coming together as a team and mobilizing state resources.

The Seattle Pain Center was a large, multi-site clinic known for taking Medicare and Medicaid patients, prescribing opioids, performing interventional pain management procedures, and employing a greater number of advanced practice practitioners than physicians. In 2013, the Center was investigated by the state and the Drug Enforcement Administration (DEA) over issues dealing with the overprescribing of opioids, and 2015 brought about another investigation regarding the tightening of procedures and policies for both prescribing and care.

This triggered the interest of journalists at the Seattle Times, and on July 15, 2016, a headline in the newspaper read: “DEA, state crack down on pain doctor over opiate prescriptions, citing 18 deaths.” The previous day, the director of the Center had his license suspended, his ability to supervise physician assistants was revoked, and a protective order was issued to ensure information confidentiality. At the time, an estimated 25,000 patients — including 10,000 Medicaid patients and 200 patients with intrathecal pumps — were treated at the Center. The Times article stated that “The actions may have contributed to the deaths of 18 Medicaid patients seen by Seattle Pain Centers between 2010 and 2015.” Opioid prescriptions arising from the Center in the preceding 6 months had surpassed 8000.

This announcement led to panic among the Center’s patients and area emergency departments and primary clinic healthcare providers (HCPs). Washington State’s Emergency Department issued notices to those institutions, warning them that patients from the Center might be coming in for prescription refills.

Shortly thereafter, the healthcare community in Washington State reached several agreements, stating that: 1) The patients were not to blame for the practices that had been widespread at the Center, and that, as a consequence, their prescriptions of opioids, benzodiazepines, and baclofen for intrathecal pumps had to be refilled in order to avoid withdrawal-associated dire consequences. 2) The patients’ HCPs had to be identified, as the University of Washington could not by itself absorb 25,000 patients. Those patients who had primary care providers (PCPs) outside the Seattle Pain Center were directed to them, and those who had a pump were directed to the facility that had installed the device. 3) As those first 2 measures would take some time to go into effect, patients needing emergency refill vs a long-term commitment would be accommodated by the Emergency Department.

As those pain centers were scattered throughout the state, the response had to be widespread. However, it quickly became apparent that there were not enough pain providers to accommodate the increased number of patientst, and PCPs and emergency department colleagues had to be included in the effort. “The bottom line is, one of us couldn’t do it all — we needed a statewide response, and we needed to talk about what the state’s plan was. We needed to all work together,” said Dr Stacey. Unfortunately, the state did not have a plan for the period following the Center’s closing.

Within the next several days, local  primary care facilities received an influx of requests from panicked patients and initially refused to take on the Center’s patients. These practices then started issuing referrals without even seeing the patients. The closing of the Center was prompted by issues surrounding prescribing practices for opioids and other controlled substances, as well as by the misuse of urine toxicology testing. The requests for refills led to clinician discomfort. “But the focus really shifted to those [patients] misusing opioids, and it soon became about the opioid crisis, not the poorly treated chronic pain crisis,” added Dr Stacey.

Soon, a number of groups, including the Medical board (Medical Quality Assurance Commission [MQAC]), the Agency Medical Director’s Group, the Department of Health (DoH), and the Healthcare Authority (HCA) joined in efforts to resolve the crisis. The DoH and the HCA established a “joint incident command center,” with phone services and webinars to coordinate the response across the region. Washington State Governor Jay Inslee issued an executive order that focused on opioid use disorder and the treatment of overdose. “It is an important healthcare issue, but not necessarily all that’s involved in treating chronic pain patients,” stated Dr Stacey, but as “it was what was killing patients, it got a lot of attention.”

A tele-pain program was funded, and a hotline staffed by pharmacists and physicians was deployed. Although the focus was on opioids, “at least there was a coordinated response. And this response from MQAC was really quite helpful: they basically said, don’t abruptly stop [prescribing opioids to] patients, there is no evidence that that is a good idea…taper slowly. This was a really helpful statement from the State,” added Dr Stacey.

“When we work together, it is better for our patients, better for our society, and better for the public image of pain medicine. Much more can be done when we work together,” concluded Dr Stacey. “We do need to change the public perception problem: prescribing opioids is not treating pain. It may be a component of treating pain in a subset of chronic pain patients, but that is not what pain treatment is about.”

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Reference

1. Stacey BR. I need a refill: 8,000 patients search for a new pain home in a statewide response to a real medical crisis. Presented at: the American Academy of Pain Medicine 33rd Annual Meeting; March 16-19, 2017; Orlando, Florida.