Myrdalis Diaz-Ramirez, MD, who operates an interventional pain clinic in Sarasota, Fla., says she could be forced to close down, the victim of a regulatory backlash against a very different kind of pain clinic, "pill mills" that prescribe high volumes of opioids for profit. A new local ordinance makes no distinction between her award-winning clinic, the Comprehensive Pain Center, and the pill mills.
Until recently, the state of Florida has lagged behind many other states in passing tough laws against pill mills, so it has been up to Florida counties to push the bar. Several of them have passed ordinances that go well beyond state law. Sarasota County's new ordinance, for example, bars a pain clinic from being in the same building as a pharmacy. There happens to be a Walgreen's pharmacy in Dr. Diaz-Ramirez' building, and even though it moved in after her, the ordinance would require the pain clinic to leave. "All of this has been very pain-producing for me," she jokes, but the threat is serious.
Although the regulation applies only to Sarasota County and not the City of Sarasota, Dr. Diaz-Ramirez says the city will very likely adopt the same language. Moving her practice to a new location would be very difficult. "It's very complicated to move," she says. Not only would she have to get out of her lease, but she would also have to notify Medicare of her change of address, a process that could take several months to finalize, as she understands it. "You can lose income for six months because of it," she says.
Epicenter for pill mills
Florida is an epicenter for abuse of pain pills, with 90 of the top 100 oxycodone-purchasing physicians in the nation last year coming from the state, according to the Orlando Sentinel. Each metro area has both pill mills and legitimate clinics. For instance, Dr. Diaz-Ramirez reports the Sarasota area has about 10 physicians, including her, performing interventional pain management and also has about seven pill mills at last count. "In the past 5-8 years there has been a proliferation of businesses that go under the term pain clinic," she says. "These physicians prescribe and dispense in very high doses." They can make $1 million to $3 million a year.
In contrast, Dr. Diaz-Ramirez is trained in a wide range of pain management techniques. Other professionals using her center offer physical therapy, acupuncture and other non-drug therapies. Caregivers at the center often meet to coordinate care for a patient. The center won the Pain Society's 2011 Clinical Centers of Excellence in Pain Management Award, which went to just five pain clinics in the country for advocating useful approaches to manage pain.
Dr. Diaz-Ramirez says the award has helped bring in more referrals from local physicians, but the new patients don't necessarily get the distinction between legitimate clinics and pill mills. They sometimes ask whether they're in a pill mill. "You get all sorts of questions," she says. "An elderly person comes in and wants to know, and we have to explain to them." Speaking on back pain at a Shriners Club meeting recently, she had to answer questions for 5-10 minutes on "the pill situation in Florida," she says.
Physician to become more politically active
The biggest immediate problem confronting Dr. Diaz-Ramirez, however, is the new Sarasota County ordinance. She could not attend the meeting where the county ordinance was debated and passed. "We found out about it at the last minute and I had to stay with patients," she says. She sent her manager to speak but he was given only five minutes and his views were overshadowed by people who recited stories of loved-ones dying from overdoses at pill mills, demanding a tough crackdown. "When you stand there and talk about how this would affect us and our services, it looks selfish," she says.
Dr. Diaz-Ramirez used to stay out of local politics, but now she intends to get more involved, at least in the pill mill issue. She plans to meet with city commissioners about their planned ordinance to complement the county measure. She is warning that the new ordinance could reduce access to care for the whole community by driving legitimate operations out of town. "If we get closed down," she asks, "who's going to take care of our patients?"
Related Articles on Illegal Use of Opioids:
Florida Society of Pain Management President Says Law Enforcement Campaigns Threaten Legit Practices
Florida Board of Medicine Comes Down Hard on Pain Physicians Guilty of Fraud
How Florida Became Ground Zero for Pill Mills