I am very much in the real world although I am retired except, boards, clerkship supervision etc and occasionally still peer review articles for publication (the stats are my specialty)
There is crises just not the on that Azurelle refereed to which has been manufactured. It goes a lot deeper than just the availability. Managing patients using narcotics is simply not economically feasible for most practices in the USA.
Its much easier in Universal health care countries (Canada is someplace in between) In universal health care countrie the doc gets paid whether he he is doing “intellectual time” or open heart surgery. There is just some areas where one shouldn’t be forced to compete in an open market Healthcare is one.
Standard of care now (and it always should have) requires that a patient using narcotic pain killers be seen every 30 days ACTUALLY SEEN and evaluated. The “law” attempted to put this in effect by requiring patients get a written script from their physician every 30 days. It of course didn’t work. Docs simply wrote out the prescription and left it at the front desk. A few even mailed it.
As became apparent this wasn’t working practice committees further define what should be happening. Patient notes were subject to review to make sure these patients were actually being seen. This simply was not practical for most PCP and definitly not practical for specialists such as the neuro who sent a form letter stating that the office is no longer providing any prescriptions for any controlled meds. he wasn’t afraid of the governmet (though he might have said so) he was afraid of not being able to pay his bills.
If a doc had a 100 patients using controlled meds (It takes about 4000 charts to operate a practice so 100 is conservative,) just meeting the standard of care would take 25 hours a month. Most of those patients because of chronic illness and age are on either medicare or medicaid and the rest on some kind of PPO. What this means is his cash rembursement would be less than $4000.00 (a med check remiburses about $40.00) You can’t operate a practice on that kind of money. Thats why they are getting out. Its simple economics.
So enter pain practice. They vary in what they do. The pill mills are gone, there are those that are “integrated” meaning they don’t want to manage meds but are more than willing to charge 100.00/hour for therapies of various kinds. There are actual Pain management practice (most are hospital based) that do the integrated approach (which is hghly succesful BTW) as well as mange meds. Med management can be done by non-physicians. APRN PA etc) The basis of the narcotic management is actually pretty sensible. Yup occasionally there is pee test to measure levels. Its important not only to make sure meds aren’t overused but to know how they are being used by the body. Pill counts serve a number of purposes are they selling the pills? Are they skipping doses (which raises all manner of trouble) and on goes the list.
So how does the pain Practice do this and the regular practice can not? Pain specualists are what we call Fellowship docs meaning they have completed a specialty and the completed and additional specialty in PM. Most are anesthesiologists so they support the practice with procedures (nerve block injections etc) While the PCP practice make 40.00 for a “short appointment” the PM doc makes $1200.00 for an injection. His assistants do the $40.00 job.
Medicine is becoming specialized in all areas as it should. There are no Jack of all trades anymore. My gripe with over specializing however is far too many docs no what they can’t or shouldn’t do but they fail to know who does. The lady with migraines who got a form letter from her neuro that the office is no longer providing any prescriptions for any controlled meds should have received a referral with that letter for someone who does.
They for-profit competitive healthcare system is one of the things that creates an issue in the USA that no one else has