Re: Pain Mgmt Doctors Threaten ACOEM w/Class Action

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Now this might get their attention and some elected officials too.

On 1/28/11, Sharon Kramer wrote:
> Experts Predict Harm to Patients
>
> Timothy Deer, MD, president of the Center for Pain Relief
> in Charleston, W.Va., and chair of the American Society of
> Anesthesiologists pain committee, said that if adopted in
> their current form, the ACOEM guidelines would adversely
> affect patients.
>
> �We�ve gone to general quarters on this,� one society
> official told Pain Medicine News. �We�re talking
> litigation. We�re talking class action. We see this as
> pandering to the insurance companies,� said the clinician,
> who did not want to be identified. �The insurance companies
> will buy these guidelines and then cut and paste [the text]
> on their denials.�
>
> �We don�t want this to be the de facto standard of care
> nationwide,� said B. Todd Sitzman, MD, MPH, president of
> the American Academy of Pain Medicine (AAPM).
>
> ACOEM itself has come under recent scrutiny for its ties to
> business. The 5,000-member group, once called the
> Industrial Medical Association, was the subject of a
> January 2007 article in The Wall Street Journal that
> questioned the objectivity of an ACOEM report rejecting a
> link between mold and serious worker illness. The authors
> of the report, according to the newspaper, were researchers
> who frequently receive money to testify for companies named
> in mold suits�a fact not disclosed in the report or by
> ACOEM.
>
> Similar accusations were raised in a recent article in the
> International Journal of Occupational and Environmental
> Health (2007;13:404-426), which labeled ACOEM �a
> professional association in service to industry� and said
> that corporate �money and influence permeate every aspect
> of occupational and environmental medicine.�
>
>
>
> Proposed Guidelines for Workers� Comp Patients Roil Pain
> Specialists
>
> The nation�s pain groups have taken aim at proposed
> guidelines for the treatment of chronic pain that discount
> the utility of several staple interventional and
> noninterventional therapies, such as certain medications,
> epidural injections and spinal cord stimulation.
>
> If approved, the guidelines, from the American College of
> Occupational and Environmental Medicine (ACOEM), could
> affect the willingness of health insurers to pay for the
> procedures in question, experts said. In the rationale
> sections of its recommendations, the document frequently
> comments on the cost-effectiveness of a given therapy.
> Although interventional pain medicine is a relatively new
> field, the growth of these procedures has been strong.
> Medicare spent roughly $2 billion in 2005 on interventional
> remedies.
>
> Experts Predict Harm to Patients
>
> Timothy Deer, MD, president of the Center for Pain Relief
> in Charleston, W.Va., and chair of the American Society of
> Anesthesiologists pain committee, said that if adopted in
> their current form, the ACOEM guidelines would adversely
> affect patients.
>
> �Some need minimally invasive procedures who won�t be
> allowed to get those procedures,� Dr. Deer said. �They will
> get more back surgery�which is not supported by the data�or
> they will be on lifelong medications, including high-dose
> opioids. There will be more failed surgeries, an increased
> potential for addiction, worse outcomes, at more expense�
> to the health care system.
>
> �We�ve gone to general quarters on this,� one society
> official told Pain Medicine News. �We�re talking
> litigation. We�re talking class action. We see this as
> pandering to the insurance companies,� said the clinician,
> who did not want to be identified. �The insurance companies
> will buy these guidelines and then cut and paste [the text]
> on their denials.�
>
> �We don�t want this to be the de facto standard of care
> nationwide,� said B. Todd Sitzman, MD, MPH, president of
> the American Academy of Pain Medicine (AAPM).
>
> After ACOEM released its guidelines for the treatment of
> low back pain in 2004, California legislators mandated that
> doctors in the state use the group�s recommendations�
> outraging many physicians in the process. �We do not want
> to happen what occurred in California, where physicians�
> treatment of workers� compensation patients is dictated by
> legislation to follow ACOEM guidelines,� Dr. Sitzman said
> in an interview. (A California appeals court judge in June
> 2007 ruled that the guidelines could apply only to acute
> low back pain [LBP].)
>
> Squeaky Wheels?
>
> The societies� aggressive lobbying efforts may have paid
> off�at the very least, the push bought pain specialists a
> hearing. After initially declaring the review process
> closed, ACOEM agreed to extend its evidence review another
> six weeks, until late January, according to pain group
> officials who participated in a Dec. 5 conference call with
> ACOEM.
>
> One pain society head who sat in on the call described
> ACOEM�s tone as �more conciliatory than we anticipated.
> They informed us that they would reply to every comment
> individually.� ACOEM representatives also suggested that
> they would incorporate �substantive� comments�presumably
> those supported by evidence�into the final version of the
> guidelines, although the precise meaning of this concession
> was not clear.
>
> The 455-page document, a copy of which,
> marked �confidential,� was obtained by Pain Medicine News,
> reviews the quality of the evidence available for therapies
> and diagnostic tests for various forms of chronic pain,
> such as chronic regional pain syndrome (CRPS), fibromyalgia
> and LBP. The panel�consisting mainly of physicians but
> including no specialists in interventional pain�broke each
> therapy into three categories: recommended, no
> recommendation and not recommended.
>
> Recommended treatments for CRPS include acetaminophen,
> nonsteroidal anti-inflammatory drugs and tricyclic
> antidepressants, which are also endorsed for neuropathic
> pain.
>
> Not making the cut, however, were a litany of
> interventional techniques: epidural steroid injections for
> chronic LBP lacking �significant radicular symptoms� or as
> a �first or second line treatment in individuals with LBP
> symptoms that predominate over leg pain,� steroids for
> trigger or tender point injections, facet joint injections
> with hyaluronic acid, pain pumps, guanethidine and
> methylprednisolone for CRPS and others. The guidelines also
> reject the use of spinal cord stimulators�despite the
> recent publication in the journal Pain of a randomized
> controlled trial of the technology in patients with failed
> back surgery syndrome (2007;132:179-188).
>
> Time Pressures
>
> Andrea Trescot, MD, president of the American Society of
> Interventional Pain Practitioners (ASIPP), said her group
> had received a copy of the draft guidelines for comment but
> were told that the document would become official within a
> matter of days. �It was clear they were not looking for
> actual input,� said Dr. Trescot, director of the pain
> fellowship at the University of Florida College of Medicine
> in Gainesville. �If you truly want our input, then give us
> time to make a reasonable and measured response.�
>
> Another flaw in the process, Dr. Trescot said, is that the
> guidelines panel did not include any interventionalists,
> although two physicians, Gerald Aronoff, MD, and Steven D.
> Feinberg, MD, MPH, who served as consultants to the panel
> are AAPM members. Dr. Aronoff was president of the group in
> the mid-1980s.
>
> Still, the presence of those two specialists did not
> produce a document that satisfied their society colleagues.
>
> In a Nov. 16, 2007, letter to ACOEM President Robert K.
> McLellan, MD, MPH, Dr. Sitzman observed that the
> guidelines �are often adopted by Workers� Compensation
> carriers nationwide as part of their utilization review
> process to make coverage decisions. Failure to provide a
> fair, balanced and consistent approach could potentially
> jeopardize the care of injured workers nationwide and
> compromise the ability of Pain Medicine physicians to care
> for those workers with chronic pain.� In the letter, Dr.
> Sitzman laid out his group�s �several concerns� about the
> guidelines process and the recommendations themselves.
>
> �The document does not present a balanced view of pain
> management strategies but is clearly weighted toward non-
> interventional/non-opioid strategies,� the letter
> reads. �Rather than stating in the introduction that there
> may be roles for interventional techniques or medication
> therapy, the authors state explicitly that such approaches
> are to be avoided.�
>
> Dr. Sitzman also described the ACOEM panel�s definition of
> pain��a symptom rather than a disease��as �dogmatic.�
> Although perhaps true for some patients, he said, this
> definition ignores patients, such as those with CRPS or
> certain neuropathic pain conditions, whose pain has a
> neurobiological basis. �Unfortunately,� the letter
> adds, �this statement seems to set the tone for much of the
> document.�
>
> Lack of RCT Does Not Equal Lack of Evidence
>
> Other objections, according to Dr. Sitzman�s letter,
> include the rejection of �expert consensus opinion� as a
> valid form of scientific evidence and an unrealistic view
> of data�or lack thereof�from randomized controlled trials
> (RCTs): �There is an underlying theme that the lack of RCTs
> [for a given therapy] equates with no evidence of
> therapeutic efficacy and hence is �not recommended.�
> Absence of proof is not proof of absence.�
>
> Dr. Aronoff, who is medical director of the Carolina Pain
> Institute in Charlotte, N.C., said he did not agree with
> every provision of the ACOEM guidelines. But he defended
> the process and the end product as appropriate and
> unbiased. And although Dr. Aronoff said that he often urged
> panelists to consider the subjectivity of pain�and the
> paucity of gold-standard studies for certain interventions�
> in its deliberations, he was convinced that the guidelines
> were not arbitrary.
>
> �If the review from ACOEM shows, by citing numerous
> studies, that the data is very critical of a specific
> procedure, practitioners may have reason to rethink their
> use of that procedure,� Dr. Aronoff said.
>
> In the end, Dr. Aronoff added, clinicians need to keep in
> mind that the guidelines are not laws, merely practice
> recommendations, and that they will have little or no
> impact on pain specialists who treat few or no workers�
> compensation patients. �A physician is able to not use the
> guidelines,� he said, �although if they do that, they would
> need to explain why.�
>
> The editor of the guidelines was Kurt T. Hegmann, MD, MPH,
> a specialist in occupational medicine at the University of
> Utah School of Medicine in Salt Lake City. Dr. Hegmann is
> named as a researcher on the document, along with a dozen
> other people.
>
> Dr. McLellan, of ACOEM, said his group had so far received
> letters from four pain societies�ASIPP, AAPM, the
> International Spine Intervention Society and the North
> American Neuromodulation Society. �The editor has seen
> these letters and has incorporated some of the suggestions
> in the most recent version of the chapter, which is still
> being finalized,� Dr. McLellan said in an interview. The
> final version of the document may be ready by the beginning
> of the new year, he said.
>
> ACOEM: �No Ax To Grind�
>
> In addition, said Dr. McLellan, an occupational medicine
> specialist at Dartmouth-Hitchcock Medical Center in
> Lebanon, N.H., ACOEM has tried to extend an olive branch to
> the pain groups, asking for a face-to-face meeting to
> discuss the guidelines. �Needless to say, when current
> practice is questioned people get concerned. I�m not
> shocked, but our goal here is to provide the best-quality
> care. We don�t have another ax to grind.�
>
> The chronic pain guidelines are not the first time ACOEM
> has angered pain specialists. The group�s recommendations
> on LBP, published as a chapter in its 2004 guidelines, were
> widely seen in the field as a significant blow.
>
> Some Say Group Is Overcozy With Industry
>
> ACOEM itself has come under recent scrutiny for its ties to
> business. The 5,000-member group, once called the
> Industrial Medical Association, was the subject of a
> January 2007 article in The Wall Street Journal that
> questioned the objectivity of an ACOEM report rejecting a
> link between mold and serious worker illness. The authors
> of the report, according to the newspaper, were researchers
> who frequently receive money to testify for companies named
> in mold suits�a fact not disclosed in the report or by
> ACOEM.
>
> Similar accusations were raised in a recent article in the
> International Journal of Occupational and Environmental
> Health (2007;13:404-426), which labeled ACOEM �a
> professional association in service to industry� and said
> that corporate �money and influence permeate every aspect
> of occupational and environmental medicine.�
>
> In a letter on ACOEM�s Web site, Dr. McLellan rejected
> those accusations, calling them a �conspiracy theory�
> that �inaccurately and unfairly characterize ACOEM�s
> historical role and current activities in occupational and
> environmental medicine and are based largely on unfounded
> and irresponsible accusations.�
>
> ACOEM Defends Pain Guidelines
> To The Editor:
>
> The American College of Occupational and Environmental
> Medicine respectfully disagrees with comments in the recent
> article �Draft Guidelines for Workers� Comp Care Roil Pain
> Field,� (Pain Medicine News, January 2008, page 1)
> suggesting that our Practice Guidelines for Chronic Pain
> are biased against pain interventionalists.
>
> We believe that our process, which adheres to standards for
> the development of guidelines established by the AGREE
> Collaboration, the Institute of Medicine and the American
> Medical Association, was fairly and consistently applied in
> the compilation of our new chapter on chronic pain. The
> Chronic Pain Panel was convened with representation from a
> broad variety of specialties, including senior pain
> specialists (two of whom are past presidents of the
> American Academy of Pain Medicine), pain interventionalists
> and a cross-section of pain-related societies. The opinions
> and judgments of pain interventionalists serving on the
> panel were heavily relied on during the development of the
> Chronic Pain guidelines.
>
> External peer review by a diverse cross-section of
> organizations and health practitioners is an essential
> component of our guideline development process and it was
> fully utilized in this case. It is also important to note
> that the guidelines reviewed by Pain Medicine News and peer
> organizations are in draft form, and have not been
> published. ACOEM�s recommendations remain under discussion
> and external comments are being considered as a part of the
> standard external peer-review process. External peer-review
> comments are considered and incorporated whenever
> consistent with our published evidence-based methodology.
>
> Regarding the quality of our evidence, as a physician-led,
> science-based organization with a focus on improving the
> health and safety of our nation�s workers, our philosophy
> has been to rely on only the highest-quality evidence in
> support of optimal health outcomes for those in the
> workplace. Appropriately, we take a fundamentally
> conservative approach to care that is built on the primary
> tenet of medicine��first, do no harm��and relies on a
> widely and internationally accepted standard for what is
> considered quality evidence. Our process for applying these
> criteria is clearly articulated in our methodology
> statements, which are publicly available, and it has been
> accepted as reasonable and satisfactory by the many
> organizations that have participated as peer reviewers of
> our guidelines. We have taken every reasonable step to
> ensure that the best evidence underlies our recommendations.
>
> Finally, ACOEM�s Practice Guidelines are not published in
> order to rigidly mandate treatments and, in fact, the
> guidelines fully acknowledge that in some cases alternative
> treatments outside the recommended course of action may be
> warranted. We are publicly on record with this position.
>
> Robert K. McLellan, MD, MPH, ACOEM president
>
>
>
>
>
> Pain Group Heads Respond
>
> Dear Editor:
>
> As presidents and past presidents of leading interventional
> pain societies, we are writing to disagree with a recent
> response by the American College of Occupational and
> Environmental Medicine (ACOEM) to concerns we have raised
> regarding ACOEM�s recently published revision to its Low
> Back Chapter and soon-to-be published Chronic Pain Chapter.
>
> First, ACOEM�s process has excluded the very experts
> qualified to evaluate a wide range of interventional pain
> therapies. Despite ACOEM�s contention that its chronic pain
> panel �was convened with representation from a broad
> variety of specialties to cover the diverse needs of pain
> patients,� the process included only two pain physicians
> with uncertain expertise in interventional pain medicine.
>
> Significantly, it also omitted two leading pain
> intervention societies in its external review�the American
> Society of Interventional Pain Physicians (ASIPP) and the
> International Spine Intervention Society (ISIS). Further,
> only one of our organizations, the North American
> Neuromodulation Society (NANS), was invited to formally
> participate in the Low Back Chapter revision; none of NANS�
> substantive recommendations was included in the final,
> published version of that document.
>
> Given the extensive number of interventions evaluated by
> ACOEM�including highly complex subspecialty areas such as
> neuromodulation�it is difficult to understand how such
> limited representation constitutes a sufficient external
> review process.
>
> Second, ACOEM contends that its practice guidelines �are
> not published in order to rigidly mandate treatments.�
> However, the efforts by ACOEM to achieve official
> recognition of its guidelines as a presumptive standard for
> medical necessity and utilization review by state workers�
> compensation programs are well known�promoting the
> practical and legal effect of rigidly mandating treatments.
>
> Third, ACOEM contends that it takes �a fundamentally
> conservative approach to care that is built upon the
> primary tenet of medicine��first, do no harm.�� However, in
> recommending against therapies such as oral opioids and
> spinal cord neurostimulators (Low Back Chapter)�therapies
> with a long and established role in treating certain forms
> of chronic, intractable pain�ACOEM assumes that such
> interventions do harm. We strongly challenge this judgment
> because of the substantial evidence that they can alleviate
> the often unbearable suffering of well-selected pain
> patients.
>
> Finally, we question ACOEM�s fee-for-access approach to
> guidelines, which stands in contrast to leading medical
> societies that routinely disseminate clinical guidelines
> online, without charge, on topics within their clinical
> expertise.
>
> Unfortunately, substantial disagreements remain over the
> process used to create the ACOEM Low Back and Chronic Pain
> Guidelines. We certainly invite a continuation of this
> dialogue; however, without a substantial change in ACOEM�s
> process of guideline development and dissemination, we have
> no choice but to oppose their use by public and private
> payers.
>
> Todd Sitzman, MD, MPH, Immediate Past President American
> Academy of Pain Medicine
>
> Andrea Trescot, MD, President American Society of
> Interventional Pain Physicians
>
> Milton Landers, DO, PhD, President International Spine
> Intervention Society
>
> Jaimie M. Henderson, MD, President North American
> Neuromodulation Society
>
> Joshua Prager, MD, Immediate Past President North American
> Neuromodulation Society Chair, Neuromodulation Therapy
> Access Coalition
>
> The authors have responded to directly to ACOEM and have
> made their more detailed comments available through the
> Neuromodulation Therapy Access Coalition�s Web site:
> www.neuromodulationaccess.org.
>
>
> Pain Medicine News