California pain clinic with 23 locations suddenly closes

[buddababa]

MDs, DOs, PAs, NPs, CNS, CRNAs, CNMs

Correction: PAs, NPs, CNS, CRNAs, CNMs

We are not providers. MD/DO are physicians.

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Members don't see this ad.

 

[Ferrismonk]

Correction: PAs, NPs, CNS, CRNAs, CNMs

We are not providers. MD/DO are physicians.

Don't blame me, that's what the video said.

 

[pastafan]

Disregard the saying "not my circus, not my monkey" at your own peril.

 

[Nodolor]

Disregard the saying "not my circus, not my monkey" at your own peril.

What are they going to do if you don't Rx?

 

[deleted875186]

Honestly, this should be in opioid consent/agreements, that if your physician retires or clinic closes, it may be challenging to find another prescriber. It’s also a reason to never increase dose beyond 30 MME or a reasonable dose.

 

[Gauss]

this got the attention of the Med board of CA who just sent this out last week: https://www.cdph.ca.gov/Programs/CC...iders-Who-Inherit-Patients-on-Opioids_ADA.pdf

 

[deleted875186]

this got the attention of the Med board of CA who just sent this out last week: https://www.cdph.ca.gov/Programs/CCDPHP/sapb/CDPH Document Library/SOS-Workgroup-Action-Notice-Best-Practices-for-Providers-Who-Inherit-Patients-on-Opioids_ADA.pdf

We should take on patients we never chose to escalate to ridiculous doses of opioids inappropriately …. Not a chance. Have met very few if any of these high dose opioid referrals that had reasonable expectations or were good patients, that’s how they got on these high doses. It’s honestly a risk to even see these patients and taper them.

 

[Ferrismonk]

We should take on patients we never chose to escalate to ridiculous doses of opioids inappropriately …. Not a chance. Have met very few if any of these high dose opioid referrals that had reasonable expectations or were good patients, that’s how they got on these high doses. It’s honestly a risk to even see these patients and taper them.

100% agree. If they really want people to take on these patients as a public health issue, they will suspend any potential legal issues from prescribing to these patients.

 

[bedrock]

100% agree. If they really want people to take on these patients as a public health issue, they will suspend any potential legal issues from prescribing to these patients.

And pay double Medicare rates for the hassle.

 

[deleted875186]

And pay double Medicare rates for the hassle.

How about they all get sent to the methadone clinic, let them go every day and get a potent opioid, would be much less diversion and misuse of opioids.

 

[NJPAIN]

How about they all get sent to the methadone clinic, let them go every day and get a potent opioid, would be much less diversion and misuse of opioids.

THIS. Government regulated, strict guidelines and no second chances.

 

[NJPAIN]

COT is simply not a “portable” therapy.

 

[Ducttape]

i have taken some high dose opioid patients who lost their primary prescriber. in almost all cases, the goal is to taper to a reasonable (<90) MED.

it takes a lot of screening and "gut feeling" to find those who would be appropriate. a very important and somewhat neglected aspect is to be able to ascertain how much insight a patient has to their pain and their treatment. yes, psychology...

those fixated on opioids are bound to fail and there is nothing i can offer.

 

[lobelsteve]

i have taken some high dose opioid patients who lost their primary prescriber. in almost all cases, the goal is to taper to a reasonable (<90) MED.

it takes a lot of screening and "gut feeling" to find those who would be appropriate. a very important and somewhat neglected aspect is to be able to ascertain how much insight a patient has to their pain and their treatment. yes, psychology...

those fixated on opioids are bound to fail and there is nothing i can offer.

Praise be to ye.

 

[ziggyziggy]

this got the attention of the Med board of CA who just sent this out last week: https://www.cdph.ca.gov/Programs/CCDPHP/sapb/CDPH Document Library/SOS-Workgroup-Action-Notice-Best-Practices-for-Providers-Who-Inherit-Patients-on-Opioids_ADA.pdf

and this ...

Conclusions and Relevance Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Opioids

This study examines whether there are associations between opioid dose tapering and subsequent rates of overdose and mental health crisis among patients prescribed stable, long-term, high-dose opioids.

jamanetwork.com

 

[drusso]

and this ...

Conclusions and Relevance Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Opioids

This study examines whether there are associations between opioid dose tapering and subsequent rates of overdose and mental health crisis among patients prescribed stable, long-term, high-dose opioids.

jamanetwork.com

These findings need to replicate in a prospective, blinded, RCT before anyone can make any recommendations about tapering.

 

[hyperalgesia]

Latest season of Goliath on Amazon just released. All about opioids.

Entertaining TV!

 

[Ferrismonk]

i have taken some high dose opioid patients who lost their primary prescriber. in almost all cases, the goal is to taper to a reasonable (<90) MED.

it takes a lot of screening and "gut feeling" to find those who would be appropriate. a very important and somewhat neglected aspect is to be able to ascertain how much insight a patient has to their pain and their treatment. yes, psychology...

those fixated on opioids are bound to fail and there is nothing i can offer.

That's very kind of you.

I used to do this, but EVERY SINGLE ONE complained every month until they either found some other candy man who would give them more (usually their old PCP who would subsequently no longer refer to me) or they got discharged by repeated opiate contract violations. If the patient was computer literate I received poor reviews.

Not doing that anymore.

 

[manowar rules]

That's very kind of you.

I used to do this, but EVERY SINGLE ONE complained every month until they either found some other candy man who would give them more (usually their old PCP who would subsequently no longer refer to me) or they got discharged by repeated opiate contract violations. If the patient was computer literate I received poor reviews.

Not doing that anymore.

This sounds about right. I actually was able to taper 2 people off high dose opiates. But they were very motivated. While nice, cooperative tapers are in the extreme minority.

And even worse, you don’t want to get known to the PCPs as the guy who can taper patients off opiates.

 

[oreosandsake]

hypothetical
let's say patient shows up for eval. referred by PCP. old pill doc suddenly shut down...

50s F, lumbar fusion. chronic opioids. historic MED like 60-90. now norco 10s TID. chronic 60 tabs xanax every month for years.

whats your next move? who rx opioids when they are on benzos? you ever tell patient's you can discuss opioids once they have their anxiety (benzo dependence) managed with non benzo anxiolytic?

 

[drusso]

hypothetical
let's say patient shows up for eval. referred by PCP. old pill doc suddenly shut down...

50s F, lumbar fusion. chronic opioids. historic MED like 60-90. now norco 10s TID. chronic 60 tabs xanax every month for years.

whats your next move? who rx opioids when they are on benzos? you ever tell patient's you can discuss opioids once they have their anxiety (benzo dependence) managed with non benzo anxiolytic?

Taper and DC benzos. They cause brain damage. Do they meet the criteria for OUD and chronic pain? Flip to Suboxone. Rinse, lather, repeat.

 

[lobelsteve]

hypothetical
let's say patient shows up for eval. referred by PCP. old pill doc suddenly shut down...

50s F, lumbar fusion. chronic opioids. historic MED like 60-90. now norco 10s TID. chronic 60 tabs xanax every month for years.

whats your next move? who rx opioids when they are on benzos? you ever tell patient's you can discuss opioids once they have their anxiety (benzo dependence) managed with non benzo anxiolytic?

Violates cdc and fda guidelines. Would allow bzd taper if wanted to stay on meds as legacy patient as long as reasonable pathology, multimodal care, and serial ufs appropriate.

 

[Taus]

hypothetical
let's say patient shows up for eval. referred by PCP. old pill doc suddenly shut down...

50s F, lumbar fusion. chronic opioids. historic MED like 60-90. now norco 10s TID. chronic 60 tabs xanax every month for years.

whats your next move? who rx opioids when they are on benzos? you ever tell patient's you can discuss opioids once they have their anxiety (benzo dependence) managed with non benzo anxiolytic?

Simple…. Not my circus, not my monkey….or…. I’ll do anything for love but I won’t do that

Pcp can rx or patient can go elsewhere

 

[ateria radicularis magna]

I would not take over the opioid for any patient on benzos for any reason. I tell new patients that right off the bat as soon as I come in the door and offer them a full refund if they want to stop the conversation there. Learned this the hard way.

 

[bedrock]

Simple…. Not my circus, not my monkey….or…. I’ll do anything for love but I won’t do that

Pcp can rx or patient can go elsewhere

Agree completely.

 

[Ferrismonk]

hypothetical
let's say patient shows up for eval. referred by PCP. old pill doc suddenly shut down...

50s F, lumbar fusion. chronic opioids. historic MED like 60-90. now norco 10s TID. chronic 60 tabs xanax every month for years.

whats your next move? who rx opioids when they are on benzos? you ever tell patient's you can discuss opioids once they have their anxiety (benzo dependence) managed with non benzo anxiolytic?

If you want to prescribe for whatever reason, I would say wean one or the other. Don't write the benzos yourself. If you feel the patient may decompensate by withdrawing either med, just document the heck out of your note stating all the reasons why you don't wish to rock the boat with this particular patient.

 

[oreosandsake]

Taper and DC benzos. They cause brain damage. Do they meet the criteria for OUD and chronic pain? Flip to Suboxone. Rinse, lather, repeat.

suboxone is great... if im not the one who has to hold their hands at the beginning.

all of these options are time suckers.

 

[oreosandsake]

you'd take over benzos while you taper them? i'm not sure how happy they'd be to cold turkey that one which can actually cause some issues when you stop

 

[oreosandsake]

I would not take over the opioid for any patient on benzos for any reason. I tell new patients that right off the bat as soon as I come in the door and offer them a full refund if they want to stop the conversation there. Learned this the hard way.

would really love to hear the details on this.

 

[oreosandsake]

This sounds about right. I actually was able to taper 2 people off high dose opiates. But they were very motivated. While nice, cooperative tapers are in the extreme minority.

And even worse, you don’t want to get known to the PCPs as the guy who can taper patients off opiates.

no one wants to be known as the tapering service. there should be service for that like a methadone center. for legacy patients who don't really satisfy OUD and dont want anything else from a pain specialist physician. dont want PT, injections, CBT, etc that will slowly taper over months years

i've sent patient's back to their PCPs with recommendations..

consider a 5% reduction every 2-4 weeks. clonidine q12 hr prn hydroxyzine prn....

headaches everyone and they don't want to hear it either

 

[Ducttape]

these are all tough cases.

is he working or disabled? what is his functional status?

what is his emotional and relationship status? are family/friends "sold" on his med use?

assuming he is high functioning and otherwise "appropriate", this is not the safest of combinations. he is still young, but his dose is not "high" at 30 MED. id suggest he be tapered off one or the other med (preferably the benzo and that is something none of us should be prescribing).

id offer - taper off benzo stay on Norco, consider taper down benzo switch to butrans, or stay on both and don't come back here.

 

[macman]

The lightbulb has to want to change

 

[Agast]

‘Injections, injections’: Troubling questions follow closure of big pain clinic chain

In May 2021, Lags Medical Centers, one of California’s largest chains of pain clinics, abruptly closed its doors amid a cloaked state investigation.

www.latimes.com

Interesting exposé about what was going on at these clinics. Unfortunately makes the rest of us look bad. I can’t imagine trying to get rich off of punch biopsies.

 

[geauxg8rs]

‘Injections, injections’: Troubling questions follow closure of big pain clinic chain

In May 2021, Lags Medical Centers, one of California’s largest chains of pain clinics, abruptly closed its doors amid a cloaked state investigation.

www.latimes.com

Interesting exposé about what was going on at these clinics. Unfortunately makes the rest of us look bad. I can’t imagine trying to get rich off of punch biopsies.

Or elbow injections

 

[lobelsteve]

Dirty sob’s. Rot in jail.

 

[drusso]

‘Injections, injections’: Troubling questions follow closure of big pain clinic chain

In May 2021, Lags Medical Centers, one of California’s largest chains of pain clinics, abruptly closed its doors amid a cloaked state investigation.

www.latimes.com

Interesting exposé about what was going on at these clinics. Unfortunately makes the rest of us look bad. I can’t imagine trying to get rich off of punch biopsies.

Small fiber neuropathy KOL...

Incidence of Autonomic Neuropathy Among Patients with Small Fiber Neuropathy - PM&R Meeting Abstracts

Disclosures: Francis P. Lagattuta, MD: Nothing to disclose Objective: To determine the incidence of autonomic neuropathy and small fiber neuropathy on patients with symptoms combatable with autonomic neuropathy. Design Retrospective cohort Setting: Pain management clinic Participants : 35...

pmrjabstracts.org

 

[Ligament]

Keys: medicaid. opioids. crime.

 

[hyperalgesia]

Disgraceful conduct.

Can we talk about his cars and jet tho?

 

[callmeanesthesia]

I really wish they wouldn’t play up how painful and dangerous routine injections are though. The pills for pokes and the egregious number of punch biopsies are bad enough as it is. Sounds like this guy is going down - wonder why he hasn’t been arrested yet.

 

[drusso]

I really wish they wouldn’t play up how painful and dangerous routine injections are though. The pills for pokes and the egregious number of punch biopsies are bad enough as it is. Sounds like this guy is going down - wonder why he hasn’t been arrested yet.

The High Volume Pain Clinic Problem or "Churn and Burn" - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

"If you’re a pain management doctor, you have to make a choice. You can either run a low or high-volume clinic. These are two very different animals.

In a low-volume clinic, your life is sane. You see between 10-15 patients a day and spend more than enough time with every patient. You don’t employ mid-level providers like physician assistants or nurse practitioners, as every visit has face-to-face time with the doctor. Your exam can be extensive and the diagnoses can be detailed and well thought out. There’s just one problem. This type of clinic will quickly bankrupt you. More on that below.

In a high-volume clinic, your day is hair on fire insane. You see between 20-40 patients a day and heavily rely on mid-levels to churn through that patient volume. Few patients get your time and attention and decisions on what’s wrong and what to do must be lightning quick. Your exams are skeletal at best. This type of clinic can be quite profitable."

 

[paindoctor2014]

Scam artists, deserve everything they get.

But, the article just basically says give opioids. Nothing else works.

 

[RoloTomassi]

The High Volume Pain Clinic Problem or "Churn and Burn" - Regenexx

Regenexx offers non-surgical, regenerative orthopedic treatment options for pain related to osteoarthritis, joint injuries, overuse conditions, spine pain, and common sports injuries.

regenexx.com

"If you’re a pain management doctor, you have to make a choice. You can either run a low or high-volume clinic. These are two very different animals.

In a low-volume clinic, your life is sane. You see between 10-15 patients a day and spend more than enough time with every patient. You don’t employ mid-level providers like physician assistants or nurse practitioners, as every visit has face-to-face time with the doctor. Your exam can be extensive and the diagnoses can be detailed and well thought out. There’s just one problem. This type of clinic will quickly bankrupt you. More on that below.

In a high-volume clinic, your day is hair on fire insane. You see between 20-40 patients a day and heavily rely on mid-levels to churn through that patient volume. Few patients get your time and attention and decisions on what’s wrong and what to do must be lightning quick. Your exams are skeletal at best. This type of clinic can be quite profitable."

Why do you have to choose between low and high volume? I would consider myself moderate volume.

 

[MitchLevi]

I know pain doctors who see 60 and higher pts per day. They spend 60 sec with each pt and use scribes.

I'm a 25-30 guy, which should be the industry norm IMO.

That's a good number for collections, you're able to make decisions with a reasonable degree of thought, and you're not burning out.

The last article posted about Lags Clinics was largely written in hyperbole.

It sounds like this place was gross, but the BS about shots is just that - BS.

 

[sloh]

I know pain doctors who see 60 and higher pts per day. They spend 60 sec with each pt and use scribes.

I'm a 25-30 guy, which should be the industry norm IMO.

That's a good number for collections, you're able to make decisions with a reasonable degree of thought, and you're not burning out.

The last article posted about Lags Clinics was largely written in hyperbole.

It sounds like this place was gross, but the BS about shots is just that - BS.

Seems like it’s the biopsies that really raised a red flag

 

[bedrock]

I know pain doctors who see 60 and higher pts per day. They spend 60 sec with each pt and use scribes.

I'm a 25-30 guy, which should be the industry norm IMO.

That's a good number for collections, you're able to make decisions with a reasonable degree of thought, and you're not burning out.

The last article posted about Lags Clinics was largely written in hyperbole.

It sounds like this place was gross, but the BS about shots is just that - BS.

30 pts/day is pushing it unless a high percentage of your patients are direct injection/spine surgeon referrals.

Otherwise you will definitely miss things seeing 30 patients/day of average or higher complexity.

 

[mid|ine]

Almost everyone I know schedules follow ups at 15min, that's 4 per hour or 32 per 8 hour day.

At MGH we routinely sent patients for biopsies for SFN if suspected. Im guessing that was <1-2/week though for all the docs/fellows.

 

[ateria radicularis magna]

I know pain doctors who see 60 and higher pts per day. They spend 60 sec with each pt and use scribes.

I'm a 25-30 guy, which should be the industry norm IMO.

That's a good number for collections, you're able to make decisions with a reasonable degree of thought, and you're not burning out.

The last article posted about Lags Clinics was largely written in hyperbole.

It sounds like this place was gross, but the BS about shots is just that - BS.

60!!!!!!!!!!!

 

[Agast]

Wow, and here I thought I was lazy for limiting myself to 30 a day. But everyone comes in at different points in their treatment plan. It doesn’t take a long time to do post procedure follow ups or start someone on physical therapy.

 

[jonnylingo]

UNLESS you somehow see 25-30+ straight-forward acute radics and acute lumbar sprain/strain all day every day, there is no effing way the patient is getting time and education needed to address their pain issues.

Captain obvious here -- The traditional medical model does not address most pain pts underlying psycho-social issues. Unless you have a nurse educator and/or pain psych, how are you covering underlying psych/social issues, diet, exercise, posture/ergonomics, sleep hygiene?

Or is it just "shot or not"?

 

[buddababa]

Wow, and here I thought I was lazy for limiting myself to 30 a day. But everyone comes in at different points in their treatment plan. It doesn’t take a long time to do post procedure follow ups or start someone on physical therapy.

i limit to 20 a day, find that's a good work life balance and get good compensation