A patient's overdose made Jeoffry Gordon, MD, recognize he didn't know everything.
This article first appeared November 02, 2018 on Medpage Today.
By Cheryl Clark
Decades ago, California Gov. Jerry Brown twice named San Diego physician Jeoffry Gordon, MD, to sit on the board that licenses -- and disciplines -- the state's physicians. During those 8 years, his "DocSwat" agency aggressively went after narcotic overprescribers. It even manually searched pharmacy triplicates to proactively identify the worst offenders.
Gordon, 76, retired from his solo beach-area practice 4 years ago. He went to work part-time for a large federally qualified health center and its population of complex, low-income, and very difficult patients, many of whom had a history of substance abuse.
With 5 decades of experience, Gordon prided himself on being able to treat his patients with heart disease or diabetes -- as well as chronic pain -- all by himself, without referring them out. He'd taken the state-mandated course on managing pain and kept up with his CME.
But this summer, Gordon was criticized by his medical director and peer reviewers for his prescribing practices. As careful as he thought he was, one of his pain patients was hospitalized with a heroin overdose.
It wasn't easy for Gordon to accept. But after a period of anger and embarrassment, he acceded to his director's suggestion that he go through Physician Assessment and Clinical Education (PACE), a set of physician re-education classes offered by the University of California San Diego (UCSD).
PACE launched the classes Gordon took -- "Physician Prescribing" and "Medical Record Keeping" -- about 20 years ago in response to requests from state medical boards, hospitals, risk management groups, and peer review committees to address common errors in prescribing, charting, and billing. Those two classes have enrolled some 5,000 clinicians -- mostly physicians -- and most take it as a condition to keep their license. Since PACE enrollment is often ordered by the medical board or peer review committees, the program is not something doctors are eager to discuss.
Gordon told MedPage Today he was not under investigation. But he, along with about 20 other clinicians in each class, checked his ego at the door of a downtown hotel for a week. He found it worth his time and the $3,000-plus cost. He hadn't known what he didn't know.
He volunteered to describe the experience in the hope it will help other providers subdue the nation's opioid epidemic.
The following has been edited for brevity and clarity.
What was it about this clinic population that was so challenging compared with your solo practice?
Gordon: Virtually all -- 90% -- of my patients were high risk. That is, most had mental illness and many had well-documented substance abuse. Some were ex-cons. Many had broken bodies from collisions or violence and presented with acute or chronic pain. Most were also homeless, and pretty much all were in capitated Medi-Cal [Medicaid] managed care. Many pain patients if they did not get relief from one dose, might take two or three, and then bump into a friend who would give them an unknown pill or a packet of heroin. Or whatever.
What happened that prompted the suggestion that you attend PACE?
Gordon: One patient in particular -- a man age 50 years plus. He'd spent 12 years in prison, used to be a drug runner, was on methadone, and his initial drug screen was positive for cocaine. He came to me for multiple non-healing MRSA [methicillin-resistant Staphylococcus aureus] abscesses in his legs due to skin popping heroin.
I put him on clonazepam to keep him from drinking alcohol, tapered his methadone, and gave him talk therapy. Then he fell off his bicycle and got a herniated disc in his neck, which I documented with MRI. He complained of excruciating pain radiating down his arm. I told his methadone clinic to raise his methadone, and gave him Norco [hydrocodone-acetaminophen] on top of that.
It didn't control his pain. I arranged neurosurgery for him, but due to his anxiety he avoided it three times. I was tapering his pain meds. Then he was admitted to the hospital with a heroin overdose.
Did that patient die?
Gordon: No, thank God.
But that's the type of patient that I felt I could handle. I mean, no clinic patient ever got a prescription from me for any narcotics without having (1) a full exam documenting the pain and the problem, whether a fracture or arthritis; (2) appropriate imaging; (3) a pain contract; and (4) a urine screen.
Other patients came to me because their former doctors decided not to prescribe narcotics anymore, and I felt that was unprofessional and unethical.
I thought I could make good clinical judgments.
But I needed to learn how to deal with patients like that. My clinic's medical director recognized the complexity of my patients, and knowing that one overdosed on heroin, suggested PACE was the way to go.
But you were reluctant. At first you were angry.
Gordon: I didn't want to be embarrassed. Earlier, I stood up in a CME course -- in front of PACE instructors I knew -- and said that as a former member of the Medical Board of California, I knew that if you document your exam, have a contract, and do urine testing, you can continue your practice of prescribing narcotics. I'm embarrassed because while that's true, it's too simplistic. Also, PACE's founder was my chief resident when I was a resident at UCSD.
Treatment protocols have evolved. But I had not kept up.
Many doctors will refer these patients to pain management specialists or psychiatrists. Why didn't you?
Gordon: In my experience, the vast majority of pain management doctors weren't interested in a patient's psychosocial circumstances or their psychiatric needs, their depression, or dysfunctional families. And they managed pain by imposing strict or arbitrary limits that didn't address these patients' core problems.
Or they would be procedure-oriented and do epidurals or joint injections.
In several cases, my patients got markedly worse in their hands: an injection made the pain worse. One patient with back pain got epidurals and was immobilized. Or they refused medication even though I felt that person could use more.
I generally had to pester pain management doctors to give me their consult, and then it was mostly repetitive, cut-and-paste, similar, cloned reports, even for different patients. Very disappointing.
What about psychiatry?
Gordon: In my experience, psychiatrists are overworked and underpaid and didn't have time to sort out issues for my complex patients.
What pain drugs did you most frequently use?
Gordon: Mainly four: Norco or morphine sulfate, extended release, and sometimes fentanyl and sometimes hydromorphone -- and all in appropriate amounts.
You mentioned your patients sometimes surprised you in bizarre ways.
Gordon: I've been blown away by several elderly ladies who came to me complaining of pain. When their urine test results were incompatible with their prescribed medicines, I ordered a blood tox screen, stat. They refused and left the clinic. That confirmed for me they'd been selling their meds.
PACE directors said most people who go to PACE may have faced investigations that threatened their license to practice. Who else took the classes, and were they resentful or bitter about having to go? Was there a lot of anger?
Gordon: There were about 20 in each class, mostly primary care physicians in private practice. I assumed that there was anger, but the participants didn't show it.
Dr. [David] Bazzo [one of the course leaders] and his team treated the students with dignity and respect. It was not like traffic school. Rather, the atmosphere was educational and participatory, not punitive.
The classes were dense and highly educational. Two telephone book-sized binders of study points.
Who made up the faculty for the pain course?
Gordon: An anesthesiologist, an addiction treatment specialist, a pharmacist who talked about sedative hypnotics, and a psychiatrist/family medicine doctor who talked about the seductive, manipulative patient. Speakers also discussed drug interactions and newer federal and state prescribing rules dealing with chronic pain.
One impressive speaker, an administrative law judge for the medical board, was extremely reassuring and sensitive. He recognized we were all there because something went wrong, and we were probably angry. Well don't be angry, he said. There's a lot of benefit that can come from this. His attitude was, you know you can do better. That was in sharp contrast to our expectation that we would get a bunch of drill instructors.
What did you learn?
Gordon: There was good data on how ordinary patients who are not mentally ill and not substance abusers can get in trouble on opioids, and that it's correlated with higher doses and longer durations. Also, if a person goes on vacation and forgets the bottle and is hurting when they return, they might go back to a fairly strong dose and they can overdose.
One of the more interesting things I learned: you don't give the same patient benzodiazepines and opioids at the same time, because they're both respiratory depressants. Also, the safer benzos that are less likely to be abused and addictive can be more dangerous when combined with opioids because they're slowly metabolized and cause more respiratory depression.
That's something that, I guess, I'm impressed after going to the class that it's a "never do it" combination. And opioids have more side effects than the medical literature had previously revealed.
Gordon: Also, if you have groups of people with the same kind of knee or hip arthritis, and you give opioids versus an NSAID like Advil or Aleve, at the end of the year their pain relief and functionality is the same. But those on opioids will have 20% more all-cause mortality. Long-term maintenance on opioids is not the same as [long-term] metformin for diabetes. I never considered it that way before.
I generally went to both classes thinking I was more knowledgeable than most about hustling patients, proper charting, and regulatory oversight. I was wrong on all counts. I generally need to have my humility tank replenished from time to time. This worked.
What did you learn from the medical records class?
Gordon: I was mandated to take this course, but I did not know why until I did.
I learned a lot about how my record keeping could be improved to document not just the multiple diagnoses and drugs for each patient, but to be precise about my assessment and treatment plan.
Was there anything you think the classes missed or didn't do well?
Gordon: They talked about headache, back pain, fibromyalgia, without once mentioning those unbelievably difficult patients who believe they can't be relieved by anything but narcotics. They didn't go there, though they had an opportunity before a bunch of eager students. Also, this class was taught without regard to one socioeconomic consideration at all. That is, there was no discussion about how to manage pain patients when so many of them are ex-cons, low income, or mentally ill.
What will you change about your practice going forward?
Gordon: Some family doctors are like quarterbacks. They see the problem and throw it to the specialist. I was different; I didn't make a lot of referrals. I had no trouble assuming responsibility for heart failure, diabetes, irritable bowel, psychiatric, and chronic pain patients, except for the few patients with cancer or rheumatic disease.
Now, I'm not sure this old family doctor should be taking care of chronic pain. I feel compelled, given all the information in this class, to refer them to pain management, or psychiatry, or somebody else.
But you said you don't have confidence that you can get good referral care?
Gordon: This speaks to my dilemma. I will recommend that my managers develop a competent team within our clinic for pain management, or my clinic should designate a specialist to see them all.
This has been a reality check. Though I feel morally and ethically obligated to help these difficult patients, I can no longer take responsibility in this strict regulatory environment, which is so intense, we are motivated to just drop these patients. I fear patients will suffer more in the end.