When Juan Carlos Roman, MD, was appointed to the Pain Management Review Committee (PMRC), created by the Arkansas State Legislature to advise the Arkansas State Medical Board and signed into law by the governor of Arkansas in 2003, he admittedly “really did not appreciate its role in our state—to help maintain and assure that good pain management is available to the people of Arkansas.”

 

“In particular, the committee helps patients with ‘chronic intractable pain’ continue to have access to and receive appropriate pain management,” said Roman, who was recommended to serve on the 5-member volunteer committee at its conception by John Wilson, MD, then president of the Arkansas Medical Society. Roman was appointed committee chair in 2009.

 

“Right now, we have a great committee of doctors,” said Roman, of fellow members Carl Covey, D. Wayne Brooks, David Cannon and Jack Dunn, all MDs serving on the advisory board. “We have frequent disagreements, but we have always remained professional and respectful. If the time ever comes when we all agree all the time, we’ll no longer need this committee. We usually come away with a consensus opinion at the end of our discussions. I’ve been surprised how many times I’ve entered a discussion with one opinion and left with a different conclusion after our meeting.”

 

Recommendations of the PMRC are based on violations of the Arkansas Medical Practices Acts and Regulations of the ASMB, said Roman.

 

“We’ve been fortunate to have ASMB attorney Bill Trice educate and guide us as to the application of these regulations, as well as the definition of ‘gross negligence’ and ‘ignorant malpractice’ of medicine as defined by Arkansas courts,” he said. “Mr. Trice’s contribution has been invaluable to our committee.” 

 

Roman said the PRMC reviews all ASMB cases concerning pain management, which usually deal with the proper prescribing of narcotics.

 

“This is an issue with many sides and concerns,” he said. “As chairman, I try to make sure all sides are heard and respected in our discussions. There’s a lot of disagreement as to how to balance narcotic use for the non-terminal chronic pain patient. The treatment of cancer patients or any patient with a terminal illness has a well-established consensus: treat the patient’s pain with as much medicine as necessary. Very little regard is given to addiction/abuse risk.”

 

Under-treatment of cancer pain is also considered gross negligence, Roman pointed out. 

 

“With the rise of physicians specializing in hospice medicine, the issue seems to be well addressed in Arkansas,” he said. “A complaint of under-treated cancer pain has yet to be seen by the PRMC. I think that’s a great testimony to our hospice physicians and excellent training by primary care physicians and cancer specialists in Arkansas. I’d also have to compliment our pharmaceutical industry for the innovative drug and drug delivery systems they’ve developed.”

 

The real debate comes with the treatment of chronic non-terminal pain patients. “There’s a range of opinions in this matter,” he said. “Some physicians readily adopt the cancer pain model for all chronic pain patients. On the other extreme are physicians who refuse to prescribe any narcotics for long-term use by chronic non-terminally ill patients. 

 

“The unfortunate reality is that prescription drug abuse has exploded into the most common form of drug misuse today. The medications available today are extremely potent, highly addictive and readily available. The main sources of these drugs are theft, online pharmacies, and physicians. The most common complaint we see on this committee comes from patient family members concerned about a loved one being over-prescribed medications. Other sources of complaints come from patients themselves, law enforcement, pharmacists, other physicians, or an anonymous complaint filed concerning a physician. 

 

“The ASMB is obligated to inquire into each complaint. Many complaints are easily dismissed; other cases demonstrate episodes of multiple patient deaths and overdoses attributed to the prescribing habits of a single physician. The findings and opinions of our committee vary, but we usually reach a consensus after debate.” 

 

In keeping with the ASMB objective to protect the public, the PRMC must strike a balance to protect the integrity of medicine so that patients with chronic intractable pain may continue to have access to physicians willing and able to prescribe narcotics and provide them with the adequate pain relief for their medical problems, Roman explained. 

 

“One risk to maintaining access to good pain management is that the more tragedies occurring due to prescription drug misuse, the more involved the government becomes,” he said. “This can be in the form of more regulation, more stringent rules for writing prescriptions, more FDA scrutiny, and a more aggressive and intrusive DEA.”

 

The current regulatory response involving REMS (Risk Evaluation Mitigation Strategies) is a topic in and of itself, Roman noted.

 

“The problem lies in the nature of the drugs themselves and a culture by which some physicians see no downside to aggressive narcotic drug prescribing,” he said. “There’s an uncanny and obvious correlation between large quantities of potent narcotics prescribed to a patient and human tragedy. The records speak for themselves. Too many examples of young people, fathers, mothers, brothers, sisters, and children are dying or having their lives disrupted by the overwhelming power of prescription drugs. This problem knows no boundaries, from the rich and famous—Michael Jackson and Heath Ledger, for example—to our very own friends and families.”

 

Specifically, the ASMB regulations the committee mostly deals with concern opioids prescribed for pain 2.4 and 2.6, said Roman.