Pain Clinic Chain to Pay $11M to Settle Fraud Claims

By Don Thompson, KFF Health News

The owner of one of California’s largest chains of pain management clinics has agreed to pay nearly $11.4 million to California, Oregon, and the federal government to settle allegations of Medicare and Medicaid fraud.

The U.S. Department of Justice and the states’ attorneys general say Francis Lagattuta, a physician, and his Lags Medical Centers performed — and billed for — medically unnecessary tests and procedures on thousands of patients over more than five years.

It was “a brazen scheme to defraud Medicare and Medicaid of millions of dollars by inflicting unnecessary and painful procedures on patients whom they were supposed to be relieving of pain,” Phillip Talbert, U.S. attorney for the Eastern District of California, said in a statement this month.

The federal Medicare program suspended reimbursements to Lags Medical in June 2020, and Medi-Cal, California’s Medicaid program, followed in May 2021. Lags Medical shut down the same day the state suspended reimbursements. The company, based in Lompoc, California, had more than 30 pain clinics, most of them in the Central Valley and the Central Coast.

A KFF Health News review last year found the abrupt closure left more than 20,000 California patients — mostly working-class people on government-funded insurance — struggling to obtain their medical records or continue receiving pain prescriptions, which often included opioids.

Lagattuta and Lags Medical did not admit liability under the settlement. Lagattuta denied the governments’ claims, saying in a statement he was “pleased” to announce the settlement of a “long-standing billing dispute.” As part of the agreement, Lagattuta will be barred for at least five years from receiving Medicare and Medicaid reimbursements.

“Since the Centers have been closed for a couple of years, it made sense for Dr. Lagattuta to settle the dispute and continue to move forward with his other business interests and practice,” Malcolm Segal, an attorney for Lagattuta and the centers, said in the statement.

According to state officials, the federal government will receive the bulk of the money, about $8.5 million. California will receive about $2.7 million, and an additional $130,000 will go to Oregon. The settlement amount is based in part on Lagattuta’s and Lags Medical’s “ability to pay.” It does not cover the governments’ full losses, which the U.S. attorney’s office in Sacramento said are not public record.

Blanket Orders for Unnecessary Tests

A nearly four-year investigation by federal officials and the California Department of Justice found that from March 2016 through August 2021, Lagattuta and his company submitted reimbursement claims for unneeded skin biopsies, spinal cord stimulation procedures, urine drug tests, and other tests and procedures.

Lagattuta began requiring all his clinics to perform various medical procedures on every patient, the officials said, no matter if they were needed or requested by patients’ medical providers. Patients who refused were told they would have their pain medication reduced and could suffer adverse medical consequences.

U.S. and California investigators piggybacked on a federal claim filed in late 2018 by a whistleblower, Steven Capeder, Lags Medical’s former operations and marketing director, who will receive more than $2 million of the settlement.

As part of the settlement, Lagattuta and his company acknowledged that in mid-2016 he began requiring his providers to do at least two to three skin biopsies on Medicare patients each day and told providers to quit if they wouldn’t comply. Such biopsies are used to measure small-fiber neuropathy, which causes burning pain with numbness and tingling in the feet and lower extremities.

According to the settlement, a monthly report in early 2018 set a goal of performing 250 biopsies a week. Lagattuta created a separate team that was required to order at least 150 biopsies weekly, often overruling providers. And the company’s chief executive officer in late 2019 texted Lagattuta to report a particularly high number of biopsies, illustrating the text with emojis of a money bag and a smiley face.

Authorities said Lagattuta violated regulations requiring that skin biopsy results be interpreted by a trained pathologist or neurologist. Instead, they say, Lagattuta had the biopsies read by a family member who had no formal medical training and by a former clinic executive’s spouse, who was trained as a respiratory therapist.

Lags Medical clinics performed more than 22,000 biopsies on Medi-Cal patients from 2016 through 2019.

The settlement also alleges Lagattuta encouraged unsuitable patients to undergo spinal cord stimulation. It describes the procedure as “an invasive surgery of last resort,” in which implants placed near the spinal cord apply low-voltage electrical pulses to nerve fibers.

Lagattuta paid a psychiatrist $3,000 each month to falsely certify that every Lags Medical candidate for the procedure had no psychological or substance use disorders that would negatively affect the outcome, according to the settlement. For instance, the settlement says the psychiatrist overruled a Lags Medical social worker to OK the procedure for a young woman who had bipolar disorder with hallucinations that included hearing a man’s voice ordering her out of bed.

He also issued blanket orders for every patient to have urine drug testing, a policy the company’s CEO said “should be a big money maker.”

KFF Health News found that from 2017 through 2019 nearly 60,000 of the most extensive urine drug tests were billed to Medicare and Medi-Cal under Lagattuta’s provider number. Medicare reimbursed Lagattuta $5.4 million for those tests.

The clinics “carefully examined, tested, and treated” more than 60,000 patients during the time covered by the settlement, “when others might have been content to prescribe medication to mask pain,” said Lagattuta’s statement. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

The Era of No Diagnosis

By Dr. Forest Tennant, PNN Columnist

Recently I was given a report written by a prestigious professional pain organization proposing that “back pain” should be the only diagnosis assigned to this condition.  They want to do away with any diagnosis like herniated disc, arachnoiditis, sprain, strain or rheumatoid spondylitis.  Their rationale was that pain treatment should be the same for every case of back pain, therefore there is no need to make a causative, underlying diagnosis for each patient. 

To me, their motivation was clear.  It takes training, time, expertise and money to make a correct medical diagnosis, and this group only wanted to treat the symptom of pain.  Or maybe they just want robots to take a pain complaint and exercise a preconceived, no-human touch medical protocol as treatment?

This non-diagnostic proposal goes along with the large number of papers that wish to declare pain a disease rather than a symptom.  Let us be abundantly clear:  Pain, as a symptom, can be part of a disease, syndrome, disorder or condition, but pain itself is not a disease.

Some diseases definitely cause pain. Good common sense medical practice has included, and should continue to include, a search for the basic cause of an individual’s pain. What’s more, the focus should be on treating the cause of pain rather than just treating the symptom of pain. Diagnosis is the process of identifying the cause of illness whether it be a disease, condition or injury.

My recent experience in studying adhesive arachnoiditis (AA) has revealed some pathetic information about the failure of some doctors to make a diagnosis.  In an effort to develop prevention measures and treatment protocols, we surveyed several dozen people who developed AA after an epidural corticosteroid injection or a spinal tap.  In these cases, the individual singularly blamed the development of AA on one of these procedures. 

The amazing statistic, however, is that barely a third of these individuals could give us the diagnosis that prompted a physician to do an epidural injection or spinal tap in the first place.  Spinal taps were usually done in an emergency room, and only about half of these patients could even remember the symptoms that caused the emergency visit.

One-Size-Fits-All Treatment

A great disconnect has developed between primary care physicians, pain clinics and patients.  In most cases today, a person with neck, back or extremity pain will initially consult with their primary care physician. In many cases, the doctor will then refer the patient to the local pain clinic, expecting the clinic to determine a specific causative diagnosis and develop a patient-specific treatment plan. 

That is what usually happens when a primary care doctor refers a patient to an allergist, rheumatologist or cardiologist. The medical specialist makes a diagnosis and develops a patient specific plan that either the specialist or the referring doctor will follow while treating the patient. 

But this rarely happens today when a primary care physician refers a patient to a pain clinic.  Almost never is a specific diagnosis made, but a “one-size-fits-all” pain treatment regimen is initiated.  Or worse, the pain patient is given the diagnosis of “opioid use disorder” and placed on the addiction treatment drug Suboxone, even if they have been successfully maintained for years on opioids with no abuse issues.  The referring physician may never even see the patient again. 

The upshot of this practice is that some pain clinics are treating dozens of bonafide patients without a specific medical diagnosis other than neck, back or leg pain, or “opioid use disorder.”

There are some other unacceptable non-diagnostic scenarios these days.  Severe chronic pain is often caused by a rare obscure disease such as AA or Ehlers-Danlos Syndrome.  Patients will often obtain their unusual disease diagnosis and present it to a physician for care, who declares that he/she doesn’t accept the diagnosis. 

A patient may then dare to ask, “Then what do I have and what is the treatment?”  It’s hard to believe, but some patients are being told, “I don’t accept that diagnosis, but since I don’t have another one, I can’t treat you.”

Another story commonly told these days is the patient who complains about “pain all over” and is prescribed a long list of medications, but doesn’t receive a causative diagnosis.  Some patients have gone to a dozen or more doctors, but not one has rendered a causative diagnosis.

The opioid and COVID epidemics have obscured a lot of positive diagnostic developments that have gone on behind the scenes and which greatly assist in making a causative diagnosis. Improved blood tests for inflammatory and autoimmune markers are now available. Genetic and hormone testing can not only pin down a diagnosis, but also provide a roadmap for treatment.  And contrast magnetic resonance imaging (MRI), which distinguishes spinal fluid from solid tissue, has made the specific diagnosis of spinal canal pathologies most accessible.  

Every chronic pain patient not only deserves, but needs a specific medical diagnosis so that the basic cause of their pain can be treated, as well as relieving the symptom of pain.  Without treating the underlying cause of chronic pain, the patient is often doomed to a pained life of diminishing quality until death. 

Modern medicine now has the knowledge and technology to do better.  Why aren’t we?

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis through the Tennant Foundation’s Arachnoiditis Research and Education Project and the Intractable Pain Syndrome Research and Education Project.

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.   

Closed Pain Clinics Were ‘Always Pushing Injections’

By Anna Maria Barry-Jester and Jenny Gold, Kaiser Health News

On May 13 of last year, the cellphones of thousands of California residents undergoing treatment for chronic pain lit up with a terse text message: “Due to unforeseen circumstances, Lags Medical Centers will be closing effective May 19, 2021.”

In a matter of days, Lags Medical, a sprawling network of privately owned pain clinics serving more than 20,000 patients throughout the state’s Central Valley and Central Coast, would shut its doors. Its patients, most of them working-class people reliant on government-funded insurance, were left without ready access to their medical records or handoffs to other physicians.

Many patients were dependent on opioids to manage the pain caused by a debilitating disease or injury, according to alerts about the closures that state health officials emailed to area physicians. They were sent off with one final 30-day prescription, and no clear path for how to handle the agony — whether from their underlying conditions or the physical dependency that accompanies long-term use of painkillers — once that prescription ran out.

The closures came on the same day that the California Department of Health Care Services suspended state Medi-Cal reimbursements to 17 of Lags Medical’s 28 locations, citing without detail “potential harm to patients” and an ongoing investigation by the state Department of Justice into “credible allegations of fraud.”

In the months since, the state has declined to elaborate on the concerns that prompted its investigation. Patients are still in the dark about what happened with their care and to their bodies.

photo by Kathleen Hayden (KHN)

Even as the government remains largely silent about its investigation, interviews with former Lags Medical patients and employees, as well as KHN analyses of reams of Medicare and Medi-Cal billing data and other court and government documents, suggest the clinics operated based on a markedly high-volume and unorthodox approach to pain management. This includes regularly performing skin biopsies that industry experts describe as out of the norm for pain specialists, as well as notably high rates of other sometimes painful procedures, including nerve ablations and high-end urine tests that screen for an extensive list of drugs.

Those procedures generated millions of dollars in insurer payments in recent years for Lags Medical Centers, an affiliated network of clinics under the ownership of Dr. Francis P. Lagattuta. The clinics’ patients primarily were insured by Medicare, the federally funded program for seniors and people with disabilities, or Medi-Cal, California’s Medicaid program for low-income residents.

Taken individually, the fees for each procedure are not eye-popping. But when performed at high volume, they add up to millions of dollars.

Take, for example, the punch biopsy, a medical procedure in which a circular blade is used to extract a sample of deep skin tissue the size of a pencil eraser. The technique is commonly used in dermatology to diagnose skin cancer but has limited use in pain management medicine, usually involving a referral to a neurologist, according to multiple experts interviewed. These experts said it would be unusual to use the procedure as part of routine pain management.

KHN used Medi-Cal records to assess the volume of services performed across the entire chain. But the state could not provide totals for how much Lags Medical was reimbursed because of California’s extensive use of managed-care plans, which do not make their reimbursement rates public. Where possible, KHN estimated the worth of Medi-Cal procedures based on the set rates Medi-Cal pays traditional fee-for-service plans, which are public.

Lags Medical clinics performed more than 22,000 punch biopsies on Medi-Cal patients from 2016 through 2019, according to state data. Medi-Cal reimbursement rates for punch biopsies changed over time. In 2019 the state’s reimbursement rate was more than $200 for a set of three biopsies performed on patients in fee-for-service plans.

Laboratory analysis of punch biopsies was worth far more. Lags Medical clinics sent biopsies to a Lags-affiliated lab co-located at a clinic in Santa Maria, according to medical records and employee interviews. From 2016 through 2019, Lags Medical clinics and providers performed tens of thousands of pathology services associated with the preparation and examination of tissue samples from Medi-Cal patients, according to state records. The services would have been worth an estimated $3.9 million using Medi-Cal’s average fee-for-service rates during that period.

In that same period, Medicare reimbursed Lagattuta at least $5.7 million for pathology activities using those same billing codes, federal data shows.

‘Assembly Line’ Pain Care

Much of the work at Lags Medical was performed by a relatively small number of nurse practitioners and physician assistants, each juggling dozens of patients a day with sporadic, often remote supervision by the medical doctors affiliated with the clinics, according to interviews with former employees. Lagattuta himself lived in Florida for more than a year while serving as medical director, according to testimony he provided as part of an ongoing malpractice lawsuit that names Lagattuta, Lags Medical, and a former employee as defendants.

Former employees said they were given bonuses if they treated more than 32 patients in a day, a strategy Lagattuta confirmed in his deposition in the malpractice lawsuit. “If they saw over, like, 32 patients, they would get, like, $10 a patient,” Lagattuta testified.

The lawsuit, filed in Fresno County Superior Court, accuses a Lags Medical provider in Fresno of puncturing a patient’s lung during a botched injection for back pain. Lagattuta and the other named defendants have denied the incident was due to negligent treatment, saying, in part, the patient consented to the procedure knowing it carried risks.

Hector Sanchez, the nurse practitioner who performed the injection and is named in the lawsuit, testified in his own deposition that providers at the Lags Medical clinic in Fresno each treated from 30 to 40 patients on a typical workday.

According to Sanchez’s testimony and interviews with two additional former employees, Lags Medical clinics also offered financial bonuses to encourage providers to perform certain medical procedures, including punch biopsies and various injections. “We were incentivized initially to do these things with cash bonuses,” said one former employee, who asked not to be named for fear of retribution. “There was a lot of pressure to get those done, to talk patients into getting these done.”

In his own deposition in the Fresno case, Lagattuta denied paying bonuses for specific medical procedures.

‘Injections, Injections, Injections’

Interviews with 17 former patients revealed common observations at Lags Medical clinics, such as crowded waiting rooms and an assembly-line environment. Many reported feeling pressure to consent to injections and other procedures or risk having their opioid supplies cut off.

Audrey Audelo Ramirez said she had worried for years that the care she was receiving at a Lags Medical clinic in Fresno was subpar. In the past couple of years, she said, there were sometimes so many patients waiting that the line wrapped around the building.

Ramirez, 52, suffers from trigeminal neuralgia, a rare nerve disease that sends shocks of pain across the face so severe it’s known as the “suicide disease.” Over the years, Lags Medical had taken over prescribing almost all her medications. This included not only the opioids and gabapentin she relies on to endure excruciating pain, but also drugs to treat depression, anxiety, and sleep issues.

Ramirez said she often felt pressured to get procedures she didn’t want. “They were always just pushing injections, injections, injections,” she said. She said staffers performed painful punch biopsies on her that resulted in an additional diagnosis of small fiber neuropathy, a nerve disorder that can cause stabbing pain.

She was among numerous patients who said they felt they needed to undergo the recommended procedures if they wanted continued prescriptions for their pain medications. “If you refuse any treatment they say they’re going to give you, you’re considered noncompliant and they stop your medication,” Ramirez said.

She said she eventually agreed to an injection in her face, which she said was administered without adequate sedation. “It was horrible, horrible,” she said. Still, she said, she kept going to the office because there weren’t many other options in her town.

Lagattuta, through his lawyer, declined a request from KHN to respond to questions about the care provided at his clinics, citing the state investigation. “Since there is an active investigation, Dr. Lagattuta cannot comment on it until it is completed,” attorney Matthew Brinegar wrote in an email. Lagattuta’s license remains in good standing, and he said in his deposition in the Fresno lawsuit that he is still seeing patients in California.

Experts interviewed by KHN noted that medical procedures such as injections can have a legitimate role in comprehensive pain management. But they also spoke in general terms about the emergence of a troubling pattern at U.S. pain clinics involving the overuse of procedures. In the 1990s and early 2000s, problematic pain clinics hooked patients on opioids, then demanded cash to continue prescriptions, said Dr. Theodore Parran, who is a professor of medicine at Case Western Reserve University and has served as an expert witness in federal investigations into pain clinics.

“What has replaced them are troubled pain clinics that hook patients with the meds and accept insurance, but overuse procedures which really pay well,” he said. For patients, he added, the consequences are not benign.

“I mean they are painful,” he said. “You’re putting needles into people.”

Cash Bonuses for Procedures

Before moving to California in 1998, Dr. Francis Lagattuta lived in Illinois and worked as a team doctor for the Chicago Bulls during its 1995-96 championship season. Out West, he opened a clinic in Santa Maria, a Latino-majority city along California’s Central Coast known for its strawberry fields, vineyards, and barbecue. From 2015 to 2020, the chain grew from a couple of clinics in Santa Barbara County to dozens throughout California, largely in rural areas, as well as far-flung locations in Washington state, Delaware, and Florida.

The California portion of the chain is organized as more than two dozen corporations and limited liability corporations owned by Lagattuta. His son, Francis P. Lagattuta II, was a manager for the company.

On the Lags Medical website and in conversation with employees, the elder Lagattuta claimed he was on the vanguard of diagnosing and treating small fiber neuropathy. Much of the website has now been taken down. But pages available via an archival site claim he had pioneered a three-pronged approach to pain management that made minimal use of opioids and surgeries, instead emphasizing testing, injections, mental health, diet, and exercise.

“In keeping with his social justice values, Dr. Lagattuta plans to share these findings to the rest of the world, hopefully to help solve the opioid crisis, and end suffering for millions of people struggling with pain,” touted a biography once highlighted on the website.

Dr. Francis Lagattuta (Twitter)

Numerous Lags Medical patients interviewed by KHN said that even when they were given punch biopsies and a subsequent diagnosis of neuropathy, their treatment plan continued to involve high doses of opioid medications.

Dr. Victor C. Wang, chief of the division of pain neurology at Brigham and Women’s Hospital in Boston, said punch biopsies are occasionally used in research but are not a standard part of pain medicine. Instead, small fiber neuropathy is usually diagnosed with a simple clinical exam.

“The treatment is going to be the same whether you have a biopsy or not,” said Wang. “I always tell the fellows, you can do this test or that one, but is it really going to change the management of the patient?”

Ruby Avila, a mother of three in Visalia, remembers having the punch biopsies done at least three times during her four years as a Lags Medical patient. “I have scars down my leg,” she said. Each time, she said, providers removed a set of three skin specimens that were used to diagnose her with small fiber neuropathy.

Avila, 37, who has lived with pain since childhood, had found it validating to finally have a diagnosis. But after learning more about how common the biopsies were at Lags Medical, she was shaken. “It’s overwhelming to hear that they were doing it on a lot of people,” she said.

Sanchez, the nurse practitioner named in the Fresno lawsuit, spoke of other procedures that garnered bonuses: “Trigger point injections, knee injections, hip injections, foot injections for plantar fasciitis and elbow injections” all qualified for $10 bonuses, he said in his testimony.

Two former employees, who asked not to be named, echoed Sanchez, saying they were incentivized to do certain procedures, including injections and punch biopsies.

In his testimony in the Fresno case, Lagattuta denied paying bonuses for procedures. “It was only for the patients,” he said. “We never did it based on procedures.”

Incentive systems for a specific procedure are “completely unethical,” said Dr. Michael Barnett, an assistant professor of health policy at Harvard. “It’s like giving police officers a quota for speeding tickets. What do you think they’re going to do? I can’t think of any justification.”

Dr. Carl Johnson, 77, is a pathologist who directed Lags Medical’s Santa Maria lab from 2018 to 2021. Johnson said the only specimens he looked at came from punch biopsies, the first time in his long career as a pathologist that he had been asked to run such an analysis. On an average day, he said, he examined the slides of about 40 patients, searching for signs of small fiber neuropathy. Lagattuta gave him papers to read on peripheral neuropathy and assured him they were on the cutting edge of care for pain patients.

Johnson said he “never thought there was anything untoward going on” until he arrived on his last day and was told to pack up his belongings because the entire operation was shutting down.

Nerve Ablations and Drug Tests

Lags Medical performed other procedures at rates that also set them apart. From 2015 through 2020 — the span for which KHN had state data — Lags Medical performed more than 24,000 nerve ablations, a procedure in which part of a nerve is destroyed to reduce pain, on Medi-Cal patients. That’s more than 1 in 6 of all nerve ablations billed through Medi-Cal during that period.

An analysis of federal data also shows Lagattuta was an outlier. For example, in 2018 he billed Medicare for nerve ablations more often than 88% of the doctors in his field who performed the procedure.

Lags Medical also used the in-house lab to run drug tests on patients’ urine samples. From 2017 through 2019, Lags Medical facilities often ordered the most extensive — and expensive — set of drug tests, which check for the presence of at least 22 drugs, according to state and federal data.

For perspective, in 2019, more than 23,000 of the most extensive drug tests were ordered on Medi-Cal patients under Lagattuta’s provider number, more than double the number tied to the next highest biller. The next five top billers were all lab companies.

Overall, from 2017 through 2019, nearly 60,000 of the most extensive drug tests were billed to Medicare and Medi-Cal under Lagattuta’s provider number. Medicare reimbursed Lagattuta $5.4 million for these tests during that period. Using state fee-for-service rates, the testing billed to Medi-Cal would have been worth an estimated $6.3 million. That doesn’t include less extensive drug screens or those billed under other providers’ numbers.

Pain management experts described the use of extensive screening as unnecessary in routine pain treatment; the overuse of such tests has been the subject of numerous Medicare investigations in recent years.

Private pain clinics like Lags Medical are only loosely regulated and generally are not required to hold a special license from the state. But the physicians who work there are regulated by the Medical Board of California.

In December 2019, a patient who’d visited clinics in both Visalia and the Central Coast filed a complaint against Lagattuta with the medical board claiming, among other things, that she received biopsies that were not properly performed, that she underwent excessive testing, and that positive drug tests had been falsified. The medical board had another pain management doctor review more than 300 pages of documents and found “no deviations from the standard of care” and “did not find any over testing, or improperly performed biopsies.”

He did, however, find some record-keeping problems, including numerous procedures in which patient consent was not documented. He also found instances in which procedures were performed and repeated without documentation that they were effective. The patient who filed the complaint was given a medial branch nerve block in November 2014, followed by a radiofrequency ablation in December, and another in February. No improvements for the patient were ever noted in the charts, the investigating doctor found.

The medical board chalked it up to a record-keeping error and fined Lagattuta $350.

Opioids Needed for ‘Halfway-Normal Life’

On a warm evening in late July, Leah Munoz drove her power wheelchair around the long plastic tables at the Veterans Memorial Building in Hanford, a dusty farm town in California’s Central Valley. Senior bingo night was crowded with gray-haired players waiting for the game to begin. She found an empty spot and carefully set out $50 worth of bingo cards, alongside her collection of 14 brightly colored daubers.

Munoz, 55 and a mother of six, said she has suffered from a litany of illnesses — thyroid cancer, breast cancer, lupus, osteoarthritis — that leave her in near-constant pain. She’s been playing bingo since she was a little girl, and said it helps distract from the pain and calm her mind. She looks forward to this event all week.

Munoz was a Lags Medical patient for about four years and, while her pain never disappeared, the opioids prescribed provided enough relief for her to continue doing the things she loved. “There’s a difference between addiction and dependence. I need it to live a halfway-normal life,” Munoz said.

leah and ramon munoz

After Lags Medical closed in May, her primary care doctor initially refused to refill her opioid prescriptions. She said she called the Lags Medical offices to try to get a copy of her medical records to prove her need, and even showed up in person. But she said she was unable to get them. As the pills dwindled and the pain surged, Munoz said, it became hard to leave her home. “I missed a lot of bingo, a lot of grocery shopping, a lot of going to my grandkids’ birthday parties. You miss out on life,” she said. Ultimately, she said, her primary care doctor referred her to another pain clinic, and she was able to resume her prescription.

Even with pain medications, Munoz said, she never received true relief during her time as a patient at Lags Medical. She said she felt coerced to get several injections, none of which seemed to help. “If I didn’t get the procedures, I didn’t get the pain medication,” she said. Her husband, Ramon, a landscaper who was also a patient, received an injection there that he said left him with permanent stiffness in his neck.

Munoz knows at least five other people at bingo night who were former patients at Lags Medical. One of them, Rick Freeman, came over to her table to chat. He swayed back and forth as he walked, his knees, he explained, swollen after 35 years living with HIV. At Lags Medical, Freeman said, he felt pressured by staff to receive injections if he wanted to continue receiving his opioid prescriptions. “If you don’t cooperate with them, they would reduce your meds down,” he said.

At the front of the room, Gail Soto, who ran the event, sold bingo cards to the latecomers. Soto, 72, said she injured her back while working an administrative job at a construction company years ago and suffers from spinal stenosis, rheumatoid arthritis, and fibromyalgia. She, too, was a patient at Lags Medical for years. In addition to her opioid prescription, Soto said, she received repeated injections and three nerve ablations. At first, the ablations helped, but what staff members didn’t tell her, she said, was that the nerves they destroyed could grow back. Ultimately, she said, the procedures left her in worse pain.

Soto’s biggest concern is the spinal stimulator that she said Lags Medical surgically inserted into her back five years ago. She said the doctors told her the device would work so well that she would no longer need her pain pills. She said they didn’t explain that the device would work only two hours a day, and on one side of her body. She remained in too much pain to give up her meds, she said, and, five years later, the battery is failing.

Soto sleeps in a recliner chair in her three-bedroom mobile home in Lemoore, another small city near Hanford. It’s well kept but humble, and she and her husband keep a collection of wind chimes on the front porch that create a wave of gentle music when a breeze passes by.

The couple take good care of each other and their two beloved Chihuahuas, but life has become increasingly difficult for Soto. As the battery on her spinal stimulator has started to fail, she said, she has sudden electrical pulses that shoot up her body.

GAIL SOTO

“My husband says sometimes when I sleep that my body will just jump up in the air,” she said. But now that Lags Medical is closed, she said, she can’t find a doctor willing to remove the device. “Most doctors are telling me right now, ‘We can’t, because we didn’t [put it in]. We don’t want nothing to do with that.’”

Waitlists and Withdrawal

Audrey Audelo Ramirez said she picked up her final refill from Lags Medical on June 4 and by July 4 had no meds left to treat her pain. Ramirez said she called every pain management clinic in Fresno, but none were taking new patients.

“They left us all high and dry,” she said. “Everybody.”

In the weeks that followed the closures, county officials throughout the Central Valley saw a flood of patients on high doses of opioids in search of new providers, they said. Patients couldn’t access their medical records, so other providers had no idea what their treatments had been.

“We had to create a crisis response to it because there was no organized response at that time,” said Dr. Rais Vohra, the interim health officer for Fresno County.

Fresno County’s health system is already lean, Vohra said. Toss in this abrupt closure and you end up in the kind of crisis rarely seen in other fields of medicine: “You’d never do this with a cancer clinic,” he said. “You’d never abruptly stop chemo.”

The state asked Dr. Phillip Coffin, director of substance abuse research for the San Francisco Department of Public Health, to run provider training and persuade doctors to take on new patients. Many practices have rules against taking new patients on opioids, or will refuse to prescribe doses above certain thresholds.

“We know that when you stop prescribing opioids, some people end up with death from suicide, overdose, increased illicit opioid use, pain exacerbations. It’s really important to have a continuity, and that is not really possible in the current opioid-prescribing culture,” Coffin said. The threat to patients is so severe that the FDA issued a warning in 2019 against cutting patients off from prescription opioids.

Gina, a retired nurse who asked to be identified by only her first name for fear she’d be discriminated against by other doctors, had been a Lags Medical patient for six years. She said she called every practice she could find in her Central Coast town, and was put on a waiting list at one. Suffering from a severe case of scoliosis, she started rationing the pain pills she had come to rely on.

When she finally secured an appointment, she said, she was told by the doctor she was on “some very strong meds” and he would fill only one of her two prescriptions. “You’re like a criminal,” she said. “You’re branded as ‘we don’t trust you.’”

She started experiencing withdrawal symptoms — sweating, lost appetite, sleeplessness, anxiety. Worst of all, her pain “came back with a vengeance,” she said.

“I think about this, what I’d have been like if I’d never gone through pain management. I sometimes wonder if I’d be better off.”

As for Ramirez, her primary care doctor finally secured an appointment for her at another pain clinic, she said. It was in the same space as the old Lags Medical clinic, and she said she recognized many of the staff members. But now there was a new name: Central California Pain Management. From her perspective, it was as if nothing had changed. And she still doesn’t know whether she needs to worry about the care she received during more than four years at Lags Medical.

This story was produced by Kaiser Health News. Senior correspondent Jordan Rau and Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.

Why I Am Closing My Pain Practice

(Editor’s note: Patient abandonment is a serious and growing problem in the pain community. Thousands of patients have been discharged by doctors who have grown fearful of treating chronic pain and losing their medical licenses for prescribing opioid medication. We were recently contacted by a nurse practitioner, who offered her perspective on this disturbing trend. The author asked to remain anonymous.)

I am a nurse practitioner who has been in the field of pain management for the past 4 years. Prior to that, I spent years as an intensive care unit nurse and in primary care as an advanced registered nurse practitioner (ARNP).

Working with chronic pain patients has been the highlight of my professional career. I absolutely love my job and about 99% of my patients. I have had two complaints about me made to the Washington State Department of Health, both of which accused me of prescribing too much opioid medication to my patients. Both complaints were investigated by the state and I was found to be practicing within the standards of care -- and essentially told to continue. Which I did.

Then the Seattle Pain Centers closed in 2016, leaving thousands of untreated pain patients in the Puget Sound area. I inherited some of their patients. I felt like I had been "vetted" by the state, and believed that if I continued to do everything according to the law, I would be safe from any legal action.

In my practice, we fight ALL THE TIME for our patients, against the state, insurance companies, pharmacies and even the patient's families sometimes (when they don't understand). I'm not afraid of a good fight, because I have seen patients’ lives turned around when they are finally given the correct amount of opioids. I believe in opioid therapy.

Of course, all the tools in the box should be used, and I refer routinely to physical therapy, interventional pain specialists, surgeons, acupuncturists, chiropractors and others, in addition to prescribing opioids for pain.

Now I find how naive I have been. I have been to national conferences to learn more about pain management, and have heard the top doctors and researchers talk. One of these giants, Dr. Forest Tennant, was recently raided by the DEA. With Jeff Sessions as Attorney General, there is apparently more money being allotted to these raids and more are promised in the future. I also went to a website called "Doctors of Courage" and learned more about the DEA.

My interpretation of the facts is that it doesn't matter if I practice legally anymore. The DEA will look at my prescribing patterns, and tell me that I MUST have known that the ONLY reason any patient would get that much medication is if they are selling it on the street. And therefore, I am a "drug trafficking organization.” The Justice Department takes over the case and the provider is prosecuted.

If convicted, which seems to be the case recently, the provider becomes a felon and serves a prison term. Medical license is lost, time is served and because it is a "drug crime," asset forfeiture law may be used to confiscate everything I own.

'My Fear Is Very Real'

I am married, with a daughter still at home. I cannot do this to my family. So I am joining the legions of others who are closing their pain practices. I have just begun to tell my patients, and have had many, many tears, thoughts of both suicide and homicide, and one very special patient who told me that she will no longer be able to keep her service dog because she will be unable to care for him.

This whole thing is making me literally sick to my stomach. I've cried a million tears for my patients already, and I'm just beginning. I will be carefully weaning them all down to 90 MED per day over the next 6 months, or arranging transfer of care to anywhere the patient would like. What a joke that is -- there is no one else prescribing effective doses of opioids for chronic pain patients. If I am to be thrown in prison, it should be for that -- not for keeping them on therapy that enriches their lives.

I keep asking my husband to tell me that I am overreacting, but as wonderful and encouraging as he has always been, he is scared too.

Please tell all patients that what may have started merely as a provider being paranoid about his or her license has recently morphed into something truly dangerous for us. I will be absolutely no good to anyone, once locked up. If I can stay clear of the DEA's witch hunt, perhaps I can remain a voice of advocacy for pain patients. God help us all.

Please don't use my name if you post this. I can tell you, my fear is VERY real, and I don't want to call any attention to my practice right now. Thank you for understanding.

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Patient Shoots Two at Las Vegas Pain Clinic

By Pat Anson, Editor

A gunman who shot and wounded two people at a Las Vegas pain clinic before taking his own life has been identified as 50-year old Chad Broderick of Las Vegas.

Police say Broderick walked into the Center for Wellness and Pain Care of Las Vegas Thursday afternoon and asked for an unscheduled appointment to see a doctor. When it was refused, he pulled out a gun and started shooting in the lobby. About a dozen people were inside the clinic at the time.

“When I heard the first gunshot, I thought it was a bottle or something on the floor, like something just popped,” a patient told the Las Vegas Review-Journal.

“When I started hearing that ‘pop, pop, pop,’ I was so scared.”

“One of the most frightening experiences ever!” Neville Campbell, MD, the pain clinic’s medical director, wrote on his Facebook page soon after the shooting.

NEVILLE CAMPBELL/FACEBOOK

Campbell said there were “piercing screams” as people ran to escape the gunfire.

“As we barricaded ourself (with 5 others ) with a wooden desk behind the door in small office , the question of life, meaning and purpose overwhelmed my mind,” said Campbell. “But God is Good. He will never desert his own. Thank you for protecting my staff members.”

The two people who were hit by gunfire are expected to survive. Two others suffered minor injuries while trying to escape. Broderick died at the scene after shooting himself.

CHAD BRODERICK/FACEBOOK

Broderick’s neighbors told the Review Journal that he was a husband and father of two, who mostly kept to himself but had a friendly wave. One neighbor called Broderick a “really nice gentleman” who complained of back pain.

“He used to talk about taking pain pills,” said Welborn Williams. “He couldn’t get any sleep at night.”

Broderick’s Facebook page reveals a man who loved fishing and was a gun enthusiast. Ironically, in 2012 Broderick recommended without comment on his page a story about an employee at a Las Vegas medical clinic who was shot during an armed robbery.

The Review Journal reported that Broderick had a concealed weapons permit and five firearms. Williams said Broderick had offered to teach him about firearms.

“I hate to see anyone in pain like that,” Williams said. “But there should have been another way for him.”

In a statement on its Facebook page, the clinic thanked “all our patients and friends for your kind words and well wishes. We are grateful that everyone is ok.”

The clinic's website says its mission is to "foster an environment of healing" through interventional pain treatments such as epidural steroid injections, as well as massage, acupuncture, aromatherapy and prayer.

The Facebook statement said the clinic would probably remain closed until July 10. Its patients are being referred to another clinic in Henderson, a Las Vegas suburb.

Patient Suicide Blamed on Montana Pain Clinic

By Pat Anson, Editor

A 54-year old Montana man who apparently committed suicide earlier this month was a patient at a Great Falls pain clinic accused of mistreating patients and poorly managing their chronic pain. Bryan Spece was found dead in his Lewistown home on May 3.

“From what we know, about two weeks before his death, they had cut his pain pills back significantly. We’re not sure the exact amount. We’re trying to get ahold of his medical records,” said a family member. “When they called and told us that he’d been found with a gunshot wound, we thought someone had attacked him. Suicide was not even on our charts anywhere.”

BRYAN SPECE

"He was the last person anyone would have thought to take his own life. He was just not that guy," another family member said. "I know he was in a lot of pain and in a very dark spot."

Until recently, Spece was one of several hundred patients being treated at the Benefis Pain Management Center by Rodney Lutes, a physician assistant. The 68-year old Lutes was discharged by Benefis in March for unexplained reasons and the care of his patients was transferred to other providers at the clinic.

Many of Lutes' former patients – including some who were on relatively high doses of opioid pain medication – say they are now being “bullied” and treated like drug addicts by Benefis doctors and clinic staff. Their prescriptions for pain medication have been drastically reduced or stopped entirely. 

The Centers for Disease Control and Prevention recommends a "go slow" approach when patients are weaned or tapered to minimize symptoms of opioid withdrawal. The CDC says a "reasonable starting point" would be 10% of the original dose per week. Patients who have been on opioids for a long time should have even slower tapers of 10% a month, according to the CDC.

The Department of Veterans Affairs recommends a taper of 5% to 20% every four weeks, although in some extreme cases the VA says an initial rapid taper of 20% to 50% a day is needed

Bryan Spece's dose may have been reduced by 70 percent.

"I talked to him a few days before he died and he said they had cut him from 100 milligrams of oxycodone a day to 30. He was not doing well," a relative told PNN.

“He was one of my patients that I saw routinely. He was doing very well on the regimen I had him on,” said Lutes, who treated Spece for about three years and never saw signs of depression.

“My suspicion is that, like the rest of my patients, he got totally slammed at this pain clinic at Benefis and they probably took all his medicines away,” Lutes said. “Right now I am so angry about this happening. This was a good guy.”

According to his obituary, Spece was a gun collector, Marine Corps veteran, Oakland Raiders fan and belonged to a motorcycle club. Friends and family called him “Bonz.”

“He was a very loud fun loving kind of guy you always knew when Bonz walked into a room,” reads the obituary published in the Helena Independent Record.

But recently some noticed that Spece was depressed about his inability to work regularly because of chronic pain from carpal tunnel syndrome and an old back injury.

“He was having money issues with not being able to work as often because of the pain and with having his pain pills cut back. He was just very stressed, constantly, about it,” said a family member, who believes Benefis is "100%" responsible for Spece's death.

“The police found several text messages on his phone. He was talking to his friends there in Lewistown, stating ‘Come get my guns. I’m in so much pain, I might do something stupid.’ And then he’d laugh it off. So nobody thought he was really thinking about ending his life.”

"We extend our condolences to the family during this difficult time," Benefis spokesman Ben Buckridge said in a statement. Buckridge said Benefis could not comment any further because of patient and employee privacy rights.

“I lay awake wondering how many Bryans are also laying awake at the same time and I pray to God to please let them know that we are here for them,” says Re Ann Rothwell, a former patient of Lutes who claims Benefis dropped her “like a dirty diaper.”

Rothwell has organized a support group for Lutes’ patients and has reached about 100 of them so far. The group has formed an active online community and is trying to locate hundreds of other former Lutes' patients to offer them support. Rothwell worries there could be more suicides.

“I truly feel that we failed in the case of Bryan Spece and perhaps several others who have taken their lives because of Benefis' actions. They felt so alone and in despair that suicide was the only answer. We just do not know about them yet.  It truly breaks my heart,” she said in an email. “We just need to figure out how to reach those folks. Perhaps Bryan's death will help us find a few more folks on the brink, who we can pull back with love, support and hugs.”

In April, a disgruntled pain patient burned down a doctor's home near Great Falls, held the doctor's wife at gunpoint and killed himself during a standoff with police. David Herron was not a patient at the pain clinic, but suffered from chronic back pain and apparently had a long-standing grievance with the doctor, an orthopedic surgeon for Benefis.

The pain clinic is part of Benefis Health System, a non-profit community-based health organization that operates a hospital and provides a wide variety of medical services in Great Falls, a city of over 58,000 people in north central Montana. With over 3,000 physicians and other employees, Benefis is the largest employer in the area outside of government.

In a statement emailed to PNN last week, a Benefis pain management specialist outlined the clinic’s policy about opioid medication.

“Our clinic does not suddenly discontinue opioid prescriptions for patients unless we feel it is unsafe to continue prescribing them,” said Katrina Lewis, MD. “We know so much more now about how these drugs work than we did 20 years ago. The practice of medicine, procedures, and guidelines change over time, and we’re certainly seeing an evolution in how we care for people with chronic pain.

“We are following evidenced-based practice and recommendations of reputable pain societies in approaching the care we provide. We recognize that opioids absolutely have a place in the management of chronic pain for some patients. Our focus is to treat each patient individually with use of risk stratification and evaluation of patient pathology and co-morbidities.”

‘Dear Valued Patient’

But the form letters sent by Benefis to hundreds of Rodney Lutes’ patients in March could hardly be described as treating “each patient individually.” Patients were notified that Lutes was no longer practicing at the pain clinic, that they were being reassigned to new providers, and that their prescriptions would probably be changed. They were also told not to complain.

“Your new provider will do a thorough evaluation of all your medications and will likely make changes that he or she feels are in your best interests,” a form letter with the salutation “Dear Valued Patient” states. “Please be aware that arguing or complaining about changes in your prescriptions will not alter your clinician’s care plan.” 

“The prescriptions you will be given may not be what you are used to. It will be what is appropriate for your care,” another form letter says. “Verbal or written complaints to staff and management will not result in a change to your prescription.”

As PNN has reported, some patients also received letters stating that “all care providers” in the Great Falls area had been made aware of the changes at Benefis and “with what is going on with PA Lutes’ patients.” Many of those patients are now having trouble finding new doctors and feel they’ve been branded as addicts and drug seekers.

“We do our best to care for our patients and regret that this transition has been difficult for some. We realize we have opportunities to improve our communication with patients and will be working on that as a team moving forward. We are always looking at new ways to improve the patient experience, and we value patient feedback,” Nikki Phillips, Office Manager at the Benefis Pain Clinic, said in last week’s emailed statement.

What’s happening at Benefis is a microcosm of what’s happening all over the country. Patients are being abruptly weaned off opioids or being abandoned by doctors and pain clinics that are fearful of running afoul of the CDC’s “voluntary” prescribing guidelines, the DEA, or their own medical liability insurers.  Some providers are steering patients toward surgeries or costly “interventional” procedures that they don’t want.

At PNN, we hear regularly from chronic pain patients who were able to lead stable and productive lives for years on relatively high doses of opioids – a medical treatment that many are now denied and are told doesn't work. Many pain sufferers are in despair, increasingly disabled and having suicidal thoughts.

Until the needs of those patients are taken into consideration and appropriately balanced with society's need to prevent addiction, there will be more Bryan Speces and more grieving families.

“This man was the most happy-go-lucky man. He adored his grandchildren. He was a good time, all of the time. If he hadn’t been in so much pain, I don’t think he would have had a negative thought,” a family member told us.

“He lost a sister 12 years ago to suicide and he was always so broken up about that. He’s always said he would never do that.”

Spece’s death is still classified as a homicide because his autopsy report is incomplete. The Fergus County coroner is still awaiting results from toxicology tests.

Patients Allege Mistreatment at Montana Pain Clinic

By Pat Anson, Editor

A Montana pain clinic is under fire from patients for abruptly stopping their opioid medication, forcing them to take expensive drug tests, and steering them towards invasive and potentially dangerous procedures.

Some former patients at the Benefis Pain Management Center in Great Falls also allege they have been unfairly labeled as addicts, which has made it difficult for them to find new doctors.

“I’ve never been treated so badly in my life as I have at Benefis, to the point that I terminated my care with them, because I couldn’t do it. I couldn’t be called an addict and a junkie anymore,” says Tami Duncan, a 50-year old woman who suffers from chronic back pain.

“I’m not going back. I am done with them,” says another former patient. “It’s like I was a junkie just looking for my next fix. And that’s not the case at all.”

“You become terrified of who you are going to see next and what they are going to say and do to you,” said a current patient. “The fear of losing my job and not to mention my sanity. The fear that I am going to be labeled an addict if I don’t do what they tell me to.”

“They do not care. They do not know their patients. They do not review the records,” another current patient said. “There is so much more. Billing errors, rarely treated like a person, the wait to see doctors, and then 15 minutes (with them) and you are gone.”

The Benefis pain clinic is part of Benefis Health System, a non-profit community-based health organization that operates a hospital and provides a wide variety of medical services in Great Falls, a city of over 58,000 people in north central Montana. With over 250 physicians and about 3,000 other employees, Benefis is the largest employer in the area outside of government.

“We have some of the finest nurses and Physician Pain Management specialists, with experience second to none. This experience combined with their compassion, provide a tremendous supportive atmosphere. Our pain management team aims to help people reduce and cope with pain,” Benefis says on its website.

Some patients disagree, saying Benefis doctors are quick to label a patient as non-compliant, which has led to patients being discharged from the clinic. In a rural state such as Montana, where options for pain care are limited, that is not a threat to be taken lightly.

“Any questions or requests can be seen as combative. To try and protect ourselves we were recording our appointments. Somehow it was found out and there are now signs everywhere stating no recording or photos,” a patient told PNN.

“We are not allowed to have anyone come into the appointment with us. I am being bounced around to different providers. There is no stability. I am still receiving meds but at a fraction of what they were. To say that I am hurting would be an understatement.”

“Our clinic does not suddenly discontinue opioid prescriptions for patients unless we feel it is unsafe to continue prescribing them,” said Katrina Lewis, MD, a Benefis pain management specialist. “We have patients that have been on pretty high doses of opioids for many years but are not experiencing much relief from pain anymore and their quality of life is suffering significantly.  

A SIGN POSTED AT THE BENEFIS PAIN CLINIC

“We have to do what is medically responsible and safe for our patients. Opioids are incredibly powerful drugs. Given the choice between a patient potentially dying and a patient going into withdrawal, we have to pick withdrawal.”

In an age of opioid hysteria and misleading headlines about an overdose epidemic fueled by painkillers, pain patients around the country – including many who have been stable and compliant on opioid medication for years – are seeing their doses cutback or eliminated. Some have been discharged by doctors who are leery of scrutiny by the DEA and no longer want to treat chronic pain.

What sets the disgruntled patients at Benefis apart from everyone else is that they have formed a support group for each other. And some are speaking out publicly against a provider they feel has shamed and abandoned them. For this story, PNN interviewed over a dozen current and former patients, including some who asked to remain anonymous.

Physician Assistant Fired

Many of the problems at the Benefis pain clinic can be traced back to the firing of Rodney Lutes, a popular 68-year old physician assistant (PA) who – until he was let go -- was treating as many as 1,000 pain patients.  

RODNEY LUTES, PA

“I was thunderstruck. It totally blindsided me. I thought I was doing everything I could for the patients,” says Lutes about his firing in early March.

Lutes was told he was “no longer a good fit” at the clinic and that his position was being eliminated. He believes the real reason was that some of his patients were on high doses of opioids that exceeded clinic policy.

“They didn’t come to me and say, ‘Hey Rod, you need to fall in line here and start reducing these people.’ There was no warning whatsoever,” said Lutes. “The majority of the patients were doing very well. You always have some patients who aren’t doing well and you try to adjust their medications. I had a number of those. But otherwise I felt that the patients were doing very well on the doses they were on.”

“We respect our employees’ privacy rights and consequently cannot comment on the details of Rodney Lutes employment with Benefis,” says Keri Garman, Director of Corporate Communications at Benefis.

There is no record of any disciplinary action against Lutes by Montana’s Board of Medical Examiners. He has been licensed as a PA in the state since 1991.

“He’s compassionate and understanding. I’ve never met anybody else like him in my life,” says Tami Duncan, a patient of Lutes for 20 years. “And Benefis is crucifying that man, along with his patients.”

Duncan was on relatively high doses of oxycodone and MS-Contin for chronic back pain caused by herniated and bulging discs, arthritis and fibromyalgia. She’s also had as many as 60 epidural injections, nerve blocks and other "interventional" procedures, which not only failed to stop her back pain, but may have given her adhesive arachnoiditis, a progressive and chronic inflammation of spinal nerves that she was recently diagnosed with.

“Sometimes it feels like I’m standing in a pot of hot boiling water all day,” says Duncan. The first thing she was told by her new doctor at Benefis was that he was taking her off opioids.

“He comes in and didn’t even look at my files, didn’t even look at my record. And he told me, ‘Well Mrs. Duncan, the game plan is we’re taking you off all your medications and then we’ll terminate your care.’” she recalled. “He didn’t know anything about what was wrong with me. Didn’t know I had nerve conduction tests done to show all the nerve damage I have in both of my legs. He basically came out and said, ‘All you patients all need to go into treatment. You’re addicts.’"

“There are many scenarios that may warrant discontinuation of a particular regimen for the benefit of the patient.  Opioids can have many negative side effects for patients,” said Dr. Lewis in a lengthy statement for PNN prepared by Benefis. “We understand that this can be unsettling for patients who have been with a provider for a long period of time and who are accustomed to their care plan.”

Duncan started looking for a new pain doctor and immediately ran into problems. When she visited a pain clinic in her hometown of Havre, she was turned away without an exam or review of her medical records.

“The RN proceeded to tell me that I was a junkie, those are her words, that I was an addict and the only thing that was wrong with me is that I needed to go to treatment,” she said. “I’ve called all over the state trying to find a different pain doctor. Nobody will take me. Benefis has called every doctor in the state of Montana saying not to take any of Lutes’ patients.”

Duncan cites a letter she received from Benefis, which states: “All care providers in our community have been made aware of the changes in our clinic and with what is going on with PA Lutes’ patients.”

“It is our standard practice to send a note to referring physicians within our own health system and community to let them know of changes to the providers practicing in our clinic.  The letters never indicate the reason a person is no longer with our organization,” Kathy Hill, Benefis’ Chief Operating Officer said in the statement. “Community providers had many patients calling with concerns about whether they would be able to get in with a new provider soon enough to avoid a lapse in their medications.

“Whether or not to prescribe opioids to any patient is at the discretion of the provider. Providers were not urged either way.”

‘Nobody Will See Pain Patients’

Regardless of the reason, many former patients of Lutes are having trouble finding new doctors, a not uncommon experience in rural areas where healthcare choices are limited.

“Nobody in Great Falls will see any pain patients. I’m just sitting here in limbo doing nothing but being in pain,” said a former patient who decided to leave Benefis after her opioid medication was stopped. The doctor who replaced Lutes persuaded her to have an epidural, a decision she now regrets.  

“They’re forcing everybody to get injections,” says Adrienne Barnoski, another former patient. She and her husband Joseph, who has severe back pain, had been treated by Lutes for years.

“I’m not going to have any injections on my back after what my husband has gone through. It sometimes makes things worse,” she said.

Epidural injections have been used for decades to relieve pain during childbirth, but in recent years injections of a steroid into the epidural space around the spinal cord have increasingly been used to treat back pain.  The shots have become a common and sometimes lucrative procedure at pain clinics, where costs vary from as little as $445 to $2,000 per injection. Critics say the injections are risky, overused and often a waste of money.

“An epidural steroid injection is an invasive procedure. It has its risks. And I think a patient always has the right to decline an invasive procedure,” says Lutes. “I’ve had a couple of patients tell me (that they were told) to do epidural steroid injections and if they didn’t do the injections they were no longer going to be prescribed any medications. To me, that’s kind of like blackmail.  

“My patients are being treated very, very poorly. It’s horrible. I’ve had calls from patients or their spouses, very concerned the patient was going to commit suicide. It just scares me to death. And these were patients that were functionally doing great. And now they’re being told, sorry, we’re taking your medication away from you.”

Benefis says it does not pressure patients into having invasive procedures, but admits there could have been communication problems between doctors and their patients.

"This is not a policy or an expectation in any way. While we expect patients to be active participants in getting better, there is never a mandatory procedure,” said Nikki Phillips, BSN, Clinic Office Manager at Benefis Neurosciences. “We do our best to care for our patients and regret that this transition has been difficult for some. We realize we have opportunities to improve our communication with patients and will be working on that as a team moving forward.”

“The decision of whether or not to prescribe opioids to a patient is in no way related to their decision to have or not have other interventional procedures,” said Dr. Lewis. “Unfortunately there are some patients who come into the clinic with a preconceived notion that opioids are the answer for them, whether because of past practice within the medical community or other reasons, and overcoming that preconceived notion can be challenging.”

A major challenge for the patients who remain at Benefis is paying for their urine drug tests, which can cost as much as $1,500 and are not always covered by insurance.  For the past two years, Benefis has been working with a drug laboratory over 2,000 miles away in Georgia, one with a questionable past and a very uncertain future. For more on that part of the story, click here.

Tennessee Pain Clinics to Stop Using Opioids

By Pat Anson, Editor

One of the largest healthcare systems in Tennessee will no longer prescribe long term opioid pain medication to patients at two of its pain management clinics.

The move is the latest fallout from the prescribing guidelines released last month by the Centers for Disease for Prevention (CDC), which discourage the use of opioids for treating chronic pain. Although the CDC guidelines are voluntary and meant only for primary care physicians, many doctors around the country are adopting them and either weaning their patients off opioids or cutting them off entirely.

"This change was considered for several months in response to changing regulations and increasing national opiate addiction rates, and we began notifying physicians and patients of this decision in early April," Jerry Askew, Tennova Healthcare’s vice president of external relations said in a statement.

Tennova Healthcare is managed by the Sisters of Mercy, an organization of Roman Catholic nuns. Tennova operates a chain of 17 hospitals in Tennessee, but its new opioid policy only applies to patients at two pain clinics affiliated with Tennova hospitals in Knoxville and Turkey Creek.  

“After 30 days of your receipt of this letter, we no longer plan to provide long-term opiate pain medication to our patients,” Tennova said in a letter to patients.

“While pain medication therapy is widely used, non-opiate alternatives can be equally effective and can be generally safer for the patients who use them. The Center in Knoxville will continue to provide effective and compassionate treatment with non-opiate options including non-opioid pain medications, interventional procedures such as injections and radiofrequency ablations; referral to neurology and spine specialists; physical and aquatic therapy; weight loss strategies; acupuncture; massage therapy; and lifestyle counseling programs.”

But many of those alternative treatments do not work and are not covered by insurance, according to a recent survey of over 2,000 patients by Pain News Network and the International Pain Foundation. Three out of four patients said over-the-counter pain relievers did not help them at all and over half said non-opioid prescription drugs like Lyrica and Cymbalta are also ineffective.   

Tennessee has one of the highest rates of opioid abuse in the country. The state took a series of steps last year to limit opioid prescribing, such as requiring pharmacies to limit opioids to a 30 day supply and requiring doctors at pain clinics to regularly give patients urine drug tests.

"The bottom line is that fewer opioid prescriptions are being written and fewer Tennesseans are experiencing the downside and disastrous consequences of a painkiller addiction," said Douglas Varney, commissioner of the Department of Mental Health and Substance Abuse Services. "We are succeeding in reducing the number of prescriptions being written. We have helped more people into treatment and recovery and rallied a new generation of Tennesseans to live a life free of addiction."

But patient advocates say the crackdown on painkillers is unfairly focused on pain sufferers, not on the addicts who abuse opioid medication.

“I am seeing literally hundreds of reports from people who are being denied renewal of opioid meds which work well for them and are frequently the only medical treatments that give them any quality of life. Doctors are giving up their pain management practices for fear of prosecution by the DEA,” said Richard Lawhern, PhD, who became an advocate after his wife developed trigeminal neuralgia, a chronic facial pain disorder.

“I am convinced that the CDC guidelines are creating what we will later recognize to be a wave of patient suicides due to resurgent pain and hopelessness, as well as a surge in patients seeking out street drugs because they cannot function without pain relief and are being forced by their doctors to do so.”

In recent weeks, at least 14 people died and dozens were hospitalized in California after ingesting counterfeit pain medication made with illicit fentanyl, a powerful and deadly analgesic. Some of the victims were pain patients. Fake pain pills are being sold by dealers in the Sacramento and San Francisco Bay areas, and have also been intercepted at the California-Mexico border.

Why I’m Afraid to Go to My Pain Clinic

By Staci Dangerfield, Guest Columnist

I have an appointment to see my pain management clinic today and I am afraid.

I am always afraid before these appointments. I am afraid I'll once again be told that I am ineligible for pain medication. I am afraid that I'll again be pressed to do trigger point injections, despite their proven inefficiencies.

I am afraid that I'll be taken off one or more antidepressants and placed on others. Though I admit I am depressed, my depression has little to do with actual hormonal or emotional imbalances and a whole lot more to do with being in constant and relentless pain.

I am afraid that I will once again be passed on to a nurse practitioner or, as happens usually, a student nurse. I have yet to meet with a doctor.

I am worried that my attempts to convey my symptoms will be met with skepticism and just as often absolute negation. I feel like I am taunted by the school yard bully: "Lose weight, exercise, use positive thinking, rest more, sleep less, be more social” and so on and so on. My tears and sobs scoffed at, to the point I am distraught, giving credence to the antidepressant regime.

I am afraid that asking once again for narcotic and opioid pain relief, a proven and effective treatment for me, will lead to the “drug seeker” label. I am afraid that the moment the treatment room door closes, I will once again face dehumanization and my legitimate diagnosis becomes a game of Russian roulette.

STACI DANGERFIELD

How much more pain can I accept before I really do lose my mind and those antidepressants that I now do not need will become my lifeline to sanity, as I force my body to endure the radically painful sub-existence the doctors took an oath to prevent? Up, up, and up those dosages go until I am no longer capable of articulating my physical pain. Not that the pain goes away, mind you, because I am emotionally too numb to fight the pain.

I once read that pain is your body's way of telling you something is wrong. So why is my body being ignored in favor of shutting down my pain receptors and as a byproduct my entire emotional spectrum?

I am afraid of having to tell the pain center that my dentist ordered me 15 Norco pills because I have a massive abscess in my tooth. Today is my pain clinic appointment and tomorrow I will have three teeth extracted. Will I be punished for accepting the precious pain relief the dentist offered?

I didn't ask my dentist for pain relief. He saw my pain. He assessed how badly I needed relief and he ordered a minimal amount of medication to last the week of antibiotics, until the extraction could be done. I am afraid of the response from the pain clinic. Like a bad girl who knows she'll be severely punished.

More than anything, I am afraid of going back to the pain clinic with hope. Hope that this time there will be time to hear me. Hope that this time I will be treated humanely and with compassion. Hope that there will be a dialog of options that includes treatment of my physical pain. Hope that I will leave that clinic with a sense of peace, with a prescription for my pain. Hope that tomorrow I can wake up with a little less pain and a bit of anticipation for a better day. Hope that government stays out of my doctor’s office.

More than anything else, I want to not be afraid. I want to believe that hope is an option again.

Staci Dangerfield suffers from fibromyalgia, neuropathy, chronic fatigue, post-traumatic stress syndrome, severe anxiety, degenerative disc disease and chronic migraines. Staci lives in Alabama with her family.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

How Pain Clinics Fail Patients

By Jennifer Kain Kilgore, Guest Columnist

“You have exhausted all of your options.”

That is what I was told when I was denied as a new patient at Massachusetts General Hospital. Western medicine has officially given me the heave-ho.

Because I have a “long-standing relationship with another pain management clinic,” unless I am being referred for a specific procedure that my current doctors do not have, I am not allowed to become a patient elsewhere.

It’s so strange to reach the end of the road. It’s one thing to be told that the doctors are running out of ideas; it’s another thing entirely to have someone tell you that there is literally no other procedure in existence. All the treatments they are willing to try have been attempted. Science and research have not caught up yet. This is as good as it’s going to get.

What they’re willing to try. That’s the operative phrase here. Despite my decade of experience in the medical system, despite never exhibiting pill-seeking behavior, my pain management doctors refused to prescribe any kind of opioid safety net. If the pain gets really bad? “Go to the ER.”

Really? That’s the best you can offer? “Go to the ER”?

“I don’t think you understand,” I told my doctor. “I’ll have to quit my job. I can’t function like this.”

Shrug.

That’s the thing about pain management clinics. They do not cure. Most of the time they do not even have the power to manage. They try to dull the pain, to numb it, just long enough to get you out of their office. The problem is that pain is subjective. A finger slammed in a door can hurt worse than a fracture, and everyone thinks their pain is intolerable.

So if you keep coming back and complaining, then the problem must be in your head. Even though I told my pain doctor that I am already seeing a pain psychologist, she insisted that I meet with one in-house in order to come to terms with the “new” me. Like I’m not letting some kid sit at the lunch table with me. Play nice, you two!

I actually told her that when she said “you have to learn how to live with the ‘new you,'” not only did she make me want to murder everyone in my immediate vicinity, but she was also entirely patronizing. I’m sure I got some black mark in my medical file for that comment (“aggressive,” “argumentative,” “abusive,” etc.), but don’t tell me how to react to my issues when you have no experience dealing with them. I hope to God she never says those words to another patient.

Pain management doctors do not work well with patients who need more than the usual series of steroid injections. I’ve had the steroid injections, the ablations, the Botox in my muscles, the pills, the trigger point injections, the surgery, the infusion. There are no other procedures.

“We’ve done everything. So why are you still hurting? It must be in your head.”

Of course it’s in my head. That’s where pain is processed: IN YOUR BRAIN. My brain has learned these pain pathways, and my nervous system is constantly hyper-stimulated. It doesn’t take a Philadelphia lawyer to figure that one out.

 “Give her antidepressants. Give her nerve meds. Just don’t give her opioids.” That’s the reasoning my pain doctor kept parroting: “It’s been clinically proven that opioid medication doesn’t help chronic pain.”

I know that it doesn’t — not in the long run. Not if you take it every day, multiple times a day. All I need is a safety net for the really bad days. I was prescribed 14 Vicodin in March. Guess what? Still one left. Whole bottle of Tramadol? Untouched. I take them when I need them.

Doctors are more interested in protecting their own medical licenses than handing out medication to those who need it — which I can understand. If it were between my law license and some person I only see once a month, I’d go for the law license. For years, however, doctors over-prescribed until the government cracked down; now they under-prescribe and hope that none of their patients will notice. The pendulum has swung so far in the other direction that it’s only a matter of time before something breaks.

Pain management doctors must be frustrated with patients like me. It’s not like they’re huddled in a conference room, rubbing their hands together and muttering under their collective breath the names of patients they’re going to disappoint. I hate when I fail at my job. I’m sure they feel the same. But they are the gatekeepers, and they are in my way.

Everything that has helped recently has been found by my father, by my husband, and by me. I exercise as much as I can when the pain allows. I use a BodyBlade in order to strengthen my core muscles. I practice mindfulness and meditation. I stretch and do yoga on a daily basis. I walk at lunch. I get pain relief massages. I go to the chiropractor. I found the Quell pain relief device, which I adore and wrote about on my blog.

These are alternative forms of care, and they have been all found — wait for it — by people other than my pain management team.

We chronic pain patients truly have to be our own advocates. It is our responsibility to find the interventions that will help us. These treatments might seem strange or like some sort of hippie nonsense, but I am done being told by doctors that the pain is all in my head and that they can do nothing to help me. I will help myself. This is not the best it is going to be.

J. W. Kain is an attorney in the Greater Boston area who also works as a writer and editor in her spare time.  She has chronic back and neck pain after two car accidents.

This column is republished with permission from her blog, Wear, Tear, & Care.  

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.