Looks like another doc is going down in Virginia. Dr. Smithers is looking at 20 yrs and possibly life in prison after being convicted of ‘illegally prescribing pain medication’. This isn’t the first doctor going to prison in Virginia, nor will it be the last. Dr. Scranage was sent off for 30 years a couple years ago. Do a search for ‘pill mill’ and you’ll find similar stories from across the nation. I’m not going to try to excuse their behavior because I don’t know enough about the details of their cases. But in an era of ‘fake news’, their stories should have at least one telling without the usual inflammatory rhetoric about cash and ‘millions of pills’.

Most people are familiar by now with the arguments that pain is over-treated. Many people are also aware that just 25 years ago the Joint Commission for Accreditation of Hospitals was withholding certifications for organizations they considered too stingy with pain medications. How could medical opinion change so dramatically so quickly? Were all of our doctors idiots back then? Maybe… but not likely, and not from what I’ve witnessed. Rather, doctors fled narcotic-prescribing for fear that they would become subjects of investigation. Being accused of running a pill mill in 2019 carries the same odds of conviction as advertising witching services in Salem in the 1600’s. And accused doctors won’t find any empathy in today’s media. Instead, reporters covering these cases usually call a university doc who has never practiced in the real world knowing they’ll get the rhetoric they need. The true story is much more complicated.

I could relate to Dr. Smithers’ story in several ways. I also took the now-unusual route of setting up my own practice when I completed residency 12 years ago. I too set up in a semi-rural area, where countless blue-collar workers have had surgery for torn rotator-cuffs, disc herniations, and snowmobile injuries. Many of those injured parties were treated with opioids in the early 2000’s and abandoned by their doctors when ‘things changed’. It wasn’t so much that medical opinions changed than it was a search for answers to the opioid epidemic, which in these times means finding people or companies to blame.

When I started my private practice in 2007, I considered myself to be perfectly trained to provide opioid pain treatment*. I created a web page for the ‘Wisconsin Opioid Management Center’, a small part of my psychiatric practice where I would treat pain ‘the right way’ through collaboration with primary care providers, psychiatric support, addiction treatments, and measures to reduce the risk of diversion.

But that part of my practice never got off the ground. Within days of publishing the web site my office was flooded with phone calls from patients, patients’ relatives, and doctors’ offices. Caller after caller described being unfairly cut-off opioids by prior physicians, usually for minor infractions like missing one appointment. The callers were scattered throughout Wisconsin and the UP of Michigan and sounded desperate and physically sick.

My office manager challenged me: ‘Do you really want to take this on?” And from today’s news, I made the correct decision by deciding against it. By the time of my decision I’d taken on several patients, and I worked very hard with them to help them transition off opioids over the next few years.

From that experience I can understand the pressure Dr. Smithers was under. Practice in a small town is entirely different from practicing at, say, Brandeis University. Docs in private practice, unlike ‘experts,’ don’t have layers and layers of personnel and concrete to separate them from people who show up desperate for pain relief, sometimes without calling first for appointments. Small-town private practice docs must choose whether to be part of the community or to live on a remote hilltop, interacting only with other doctors at the closest country club.

Dr. Smithers was accused of several sensational misdeeds beyond his practice errors. He accepted only cash. He billed ‘almost $700,000’ in a span of two years for prescribing ‘a half million pills’.

* I was experienced and Board Certified in anesthesiology so I knew what non-opioid options were available for treating pain. I knew how to assess and evaluate those patients, and from working in the OR I knew the benefits and limitations of surgical procedures used to treat painful conditions. I had a good grasp of neurochemistry and neuroanatomy because of my PhD work in Neuroscience. And I assumed that my psychiatric training would help me week out the fakers and provide psychological support for those who needed it.


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