The temporary arrangement to care for Dr. Eugene Gosy’s 9,500 patients ends this week, but another doctor is stepping in to ensure the big pain management practice remains open.
Dr. James Hitt will begin working Monday as medical director. He will attempt to reorganize a private practice in Amherst rocked by Gosy’s indictment in April on federal charges of issuing illegal prescriptions and cheating the state workers’ compensation system.
Hitt’s emergence coincides with expanded initiatives in Buffalo to improve pain treatment as the nation grapples with an alarming rise in overdoses and deaths related to opioids. The latest took place Saturday, when health insurers and community organizations sponsored a major training program for primary care physicians and related personnel so that those on the front lines in health care can obtain the information needed to treat chronic pain patients.
Meanwhile, Hitt is an advocate of a more balanced approach to pain management that offers such non-narcotic treatments as acupuncture and cognitive and physical therapies. That’s a change he eventually would like to bring to the Gosy offices.
“It’s the right time to do this, to be part of the changes and have a say in how we approach the use of opioids in the community. We may be able to help lead the way,” said Hitt, who had been working in pain management with cancer patients at Roswell Park Cancer Institute and veterans at the Buffalo VA Medical Center.
Gosy’s legal problems provoked fears of a crisis. His patients became medical refugees, with few other physicians willing or able to inherit so many people dependent on or addicted to narcotic painkillers.
Three doctors – Nancy Nielsen, Robert Milch and Christopher Kerr – volunteered to fill in at Gosy & Associates in May after the practice briefly closed in the wake of the indictment. But it was a short-term fix until Aug. 1.
Nielsen, senior associate dean for health policy at the University at Buffalo’s Jacobs School of Medicine and Biomedical Sciences, and Milch, co-founder and former medical director of the Center for Hospice & Palliative Care, plan to support Hitt until he is settled into the practice. Kerr has returned to hospice, where he serves as chief medical officer.
U.S. Magistrate Judge H. Kenneth Schroeder Jr. in June approved a change in Gosy’s bail conditions that allowed the neurologist and pain medication specialist to return to his practice and, under the direction of a supervising physician, make recommendations on the use of painkillers and other narcotics.
Now, Hitt will come in as an independent contractor with the title of medical director, and supervise Gosy while the legal case plays out. After that, he said it’s possible his business arrangement will be restructured.
“The current arrangement leaves me with options, but I see this as a long-term move,” he said.
Board certified in anesthesiology and pain medicine, Hitt has focused his career on treating chronic pain because it allowed him to build relationships with patients.
“The satisfying part of medical care for me is becoming an important part of my patients’ lives,” he said.
The remaining pain management specialists in the region are flooded with patients, and quickly recruiting someone from outside the region to take over the Gosy practice while the legal case unfolded was unlikely to happen. Given the circumstances, Nielsen said things worked out well.
“Jim has been doing pain management. He is a very good guy. He’s from Western New York and knows the situation,” she said.
Stabilizing the practice
The first order of business for Hitt is stabilizing the practice. That means rebuilding a staff of nurse practitioners and physician assistants. Once that is accomplished, the practice can consider reopening to new patients, and then expand its services.
“Right now, we’re still struggling to take care of the patients we have,” he said.
His goal is to adopt a strategy promoted in the VA and elsewhere to reduce the reliance on narcotic painkillers as a first-line therapy.
“We need a more rational approach to opioids,” Hitt said. “Opioids are effective, and 10 years ago we thought they were the best tool. But we now know they can cause problems and should be one tool among a variety of treatments. We also now know that patient selection is important – in which people opioids will be effective and in which patients we should be cautious.”
It’s a challenging medical issue. Pain is subjective and difficult to measure.
That’s a key reason why primary care physicians, usually the first stop for common medical problems, are reluctant to prescribe opioids, and why Gosy’s practice became a go-to place for referrals. Experts say more training of primary care physicians in pain management is needed.
It’s a sign of how big a crisis the region faces when competing health insurers lay down their swords and partner with each other to get crucial information to ground-level physicians, who are faced with an onslaught of “inherited” patients suffering from pain and drug dependency.
“It’s like a miracle,” Erie County Health Commissioner Gale Burstein said about Saturday’s training session on the University at Buffalo’s South Campus.
“We all speak with one voice now,” said Dr. Judith Feld, an Independent Health administrator and member of Erie County’s Opioid Epidemic Task Force. “This is the first time I’ve seen so many stakeholders come together for one particular health care initiative.”
The idea is simple: provide critical assistance to physicians who soon may be seeing patients from Gosy’s practice and other area pain specialists who have closed their doors.
Dr. Paul Updike, director of chemical dependency at Catholic Health Systems, described the training as a “down and dirty, quick education response.”
Many primary care physicians don’t want to treat patients with chronic pain because of drug dependency and addiction, according to local health professionals. Gosy’s prosecution has also left many front-line physicians anxious about the possibility of getting into trouble if they make wrong decisions about patient treatment.
“It’s as much about a mindset, of how might I think through this versus a practical step approach on how to do this,” Updike said. “How do you think through a treatment regimen?”
The workshop focused on case studies and hypothetical situations. For instance: A 43-year-old man with painful diabetic neuropathy shows up at your office on 120 milligrams of Oxycontin twice a day. His pain has improved since he started taking other medications, but his attempts to quit Oxycontin have failed. What do you do?
Part of the training is how to talk with patients about difficult things, especially if patients demand a treatment program their doctor doesn’t think they should have, Updike said.
The answer shouldn’t be, “You’re out of here,” he said. “There are too many patients in need and not enough pain management physicians to take care of that need.”
The workshop was organized and funded through a partnership of public and private organizations, many of them also members of the opioid task force. They included the Erie County Department of Health and Tower Foundation; health insurers BlueCross BlueShield, Fidelis Care, Independent Health, Univera Healthcare and YourCare; UB’s School of Medicine and School of Pharmacy; Kaleida Health and Catholic Health; the Erie County Medical Society; and Catholic Medical Partners and Optimum Physician Alliance.
Hitt said the training session exemplifies a positive change in the landscape of pain management, especially with unresolved scientific questions about the effectiveness of long-term use of opioids. He stressed that it is essential to engage primary care doctors in efforts to address the epidemic misuse of narcotic painkillers.
“The issue is now on everyone’s mind,” he said.
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