1 NEVADA STATE BOARD OF MEDICAL EXAMINERS 2 3 STATE OF NEVADA 4 5 ---oOo--- 6 7 8 9 10 TRANSCRIPT OF PROCEEDINGS 11 WORKSHOP 12 March 31, 2000 13 Reno, Nevada 14 15 16 17 18 19 20 21 22 23 Reported by: Karen Bryson Certified Court Reporter #120 Page 1 1 2 3 4 APPEARANCES 5 RICHARD J. LEGARZA 6 General Counsel STATE BOARD OF MEDICAL EXAMINERS 7 1105 Terminal Way #301 Reno, Nevada 8 9 ANNE DALY 10 TERENCE J. DALY JO PRALL 11 HAROLD PRALL BEVERLY AMENT 12 ARLENE RALKO Page 2 1 RENO, NEVADA, FRIDAY, MARCH 31, 2000; 11:00 A.M. 2 ---o0o--- 3 4 MR. LEGARZA: Let the record show this is the 5 time and place set for one of the workshops to solicit 6 comments on proposed regulation in the State Board of Medical 7 Examiners. 8 We are at the offices of the board at 1105 9 Terminal Way, Suite 301, Reno, Nevada. It is Friday, March 10 31st, 2000. It is 11 o'clock in the morning. 11 Pursuant to notice duly published of this 12 workshop, a workshop was conducted yesterday in Las Vegas, 13 Nevada. This is the time and place for persons who are 14 interested in giving the board any information that they may 15 have with respect to their positions on the promulgation or 16 lack thereof of these regulations by the Nevada State Board 17 of Medical Examiners. 18 By way of background information, the Board of 19 Medical Examiners appointed a task force about two years ago 20 to promulgate regulations with respect to prescribing for 21 pain, prescribing for chronic and acute pain and for chronic 22 intractable pain in an effort to set out in regulation form 23 guidelines on the prescribing for pain by physicians in the 24 State of Nevada. 25 The base document that the task force utilized Page 3 1 were the Model Guidelines for the Use of Controlled 2 Substances for the Treatment of Pain adopted by the 3 Federation of State Medical Boards of the United States of 4 America. 5 Subsequent to the adoption of those regulations, 6 a physician in the State of Nevada and the Nevada State 7 Medical Association petitioned the Nevada State Board of 8 Medical Examiners to revoke those regulations because of the 9 regulatory nature and the mandatory nature of the 10 regulations, and requested the Nevada State Board of Medical 11 Examiners that instead of adopting the regulations based upon 12 the federation guidelines, that a petition was requested 13 pursuant to law of the State of Nevada to have the board 14 adopt by reference the model guidelines of the Federation of 15 State Medical Boards. 16 The board conducted a workshop, an informal 17 workshop with respect to those petitions earlier. At the 18 last board meeting, the board made a decision -- 19 determination and decision that that is what they would do, 20 that they would follow the request of the petition and 21 licensees of the board, and that they would revoke all of the 22 regulations that they adopted over the last about a year and 23 a half with respect to the prescribing of controlled 24 substances for pain, and that they would simply adopt by 25 reference the model guidelines of the federation. Page 4 1 Those documents, both the workshop document and 2 the model guidelines of the federation, are present in the 3 room, and it's -- I can see that looking around, that 4 everyone attending at this point in time has copies of both 5 of those documents. 6 If you have something to say that you want the 7 Nevada State Board of Medical Examiners to consider with 8 respect to the adoption or lack thereof of the model 9 guidelines, you may do so. This is the time for that. 10 I will indicate to you that there's a young lady 11 in the room who is taking down every word that is said in 12 this room, that anything you say will be on the record, a 13 transcript will be prepared, and that the Nevada State Board 14 of Medical Examiners will have the benefit of your thoughts 15 or feelings with respect to the adoption or lack thereof of 16 these regulations. 17 If you have something to say, one person will 18 speak at a time and only one person will speak at a time. 19 That person, I would request for purposes of the record, 20 please identify yourself, state your name; if you want to, 21 you may state your address, you don't have to. You may also 22 indicate what your profession is if you care to do so. 23 And you may indicate that you are either here 24 representing yourself or you're here on behalf of a group or 25 groups in the State of Nevada. Page 5 1 So I'm looking out at four individuals who are 2 seated here that may or may not have something to say with 3 respect to this. So I will simply turn to the lady to my 4 left and ask her if she has anything to propose to the board. 5 Ma'am? 6 MS. DALY: Yes, my name is Anne Daly. 7 MR. LEGARZA: Excuse me. 8 MS. DALY: Yes. 9 MR. LEGARZA: You need to spell your name for 10 the court reporter so that she will get it correct. 11 MS. DALY: All right. It's A-n-n-e; D-a-l-y. 12 I'm here today -- we do represent a group of 13 people in Carson City who couldn't be here today because 14 they're all sick, they really tried. 15 But what was I going to say -- I just prepared 16 some things that were personal to me and personal to people 17 who are in pain, and it would take me one minute to read it. 18 Is that all right? 19 MR. LEGARZA: Ma'am, you can take as much time 20 as you care. I don't want to be here much longer past five 21 o'clock this evening, but -- 22 MS. DALY: Well -- 23 MR. LEGARZA: -- this is -- 24 MS. DALY: -- I didn't bring it all. 25 MR. LEGARZA: You have the right to speak here, Page 6 1 and I don't think that anyone is going to cut you off because 2 if they do, it'll be me, and I won't. 3 MS. DALY: All right, good. Thank you. 4 MR. LEGARZA: Yes, ma'am. 5 MS. DALY: All right. Intractable pain I'm 6 thinking for the public's -- public's mind, public mind, is 7 disabling, demoralizing, and devastating especially when not 8 properly addressed and treated. 9 MR. LEGARZA: Excuse me. You're soft spoken. 10 MS. DALY: Yes. 11 MR. LEGARZA: And this lady wants to get every 12 word you say, and it's real hard for court reporters to 13 follow people when they are reading because we tend to read 14 faster than we speak. 15 So, if you would, if you would please just read 16 it slowly, and then when you're through, I would request of 17 you that you give a copy of that, if you would, to the court 18 reporter so she can attach it. 19 So I apologize for interrupting you. I want to 20 make sure she gets everything. So if you would start all 21 over again -- 22 MS. DALY: That's fine. 23 MR. LEGARZA: -- I would appreciate it. 24 MS. DALY: Okay. 25 MR. LEGARZA: Remembering that we read faster Page 7 1 than we speak. 2 MS. DALY: I prepared this as thoughts for 3 Nevada -- the Nevada State Board of Medical Examiners' 4 review, this particular public hearing today. 5 Intractable pain is disabling, demoralizing, and 6 devastating especially when not addressed and treated. 7 Uncontrolled intractable pain usually triggers a cascade of 8 new and serious problems for someone. 9 If pain is intractable, it is humane to do what 10 you can to control it. If controlled substances are the only 11 way to mediate disabling intractable pain, a patient should 12 be prescribed such substances and, of course, monitored by a 13 physician according to the patient's degree of acute or 14 chronic pain. 15 If a person requires more relief and medication, 16 he or she should be given it when one considers that physical 17 dependence and tolerance are normal psychological -- I beg 18 your pardon -- physiological consequences of extended opiate 19 therapy for pain and should not be considered addiction. 20 And this goes along with the definitions in the 21 back of this manual from the model guidelines. 22 Analgesic tolerance -- I beg your pardon, if a 23 patient requires more relief from medication -- I've already 24 read that, haven't I? 25 There is a difference, and a great one, between Page 8 1 addiction and analgesic tolerance. Analgesic tolerance is 2 the need to increase the dose of opiate to achieve the same 3 level of analgesia. It should not be considered addiction. 4 This is my understanding. 5 Human beings in chronic pain have many other 6 related problems encompassed in their chronic conditions and 7 should be treated with compassion and respect as human 8 beings. 9 The medical profession can be protected by the 10 new guidelines for administering controlled substances for 11 intractable pain and therefore be unafraid to do so. 12 And always remember, there but for the grace of 13 God go I. 14 Thank you. 15 MR. LEGARZA: Do you want to give that to the 16 court reporter to put in the record, ma'am? 17 MS. DALY: Yes. 18 MR. LEGARZA: If I may simply ask you a 19 question. 20 You do have the federation guidelines in front 21 of you; do you not? 22 MS. DALY: Yes, I do. 23 MR. LEGARZA: And have you looked at page four? 24 Do you see the definition of analgesic tolerance 25 at page four? Page 9 1 MS. DALY: Yes. 2 MR. LEGARZA: And does that definition of 3 analgesic tolerance, which is part of the board's intent here 4 to adopt these regulations by reference, do you believe that 5 that definition of analgesic tolerance is the same as yours 6 as you have set out in this exhibit? 7 MS. DALY: Yes -- 8 MR. LEGARZA: Thank you, ma'am. 9 MS. DALY: -- it is. 10 MR. LEGARZA: Seated next to you is a gentleman. 11 Do you have something to present, sir? 12 MR. DALY: My name is Terence J. Daly, 13 T-e-r-e-n-c-e, middle initial J., Daly, D-a-l-y. 14 I would just like to state that my wife has 15 fibromyalgia. I am here because I have observed her 16 suffering from severe chronic intractable pain for several 17 years, and I would urge the Board of Medical Examiners adopt 18 the guidelines, the model guidelines as written to provide a 19 safe harbor for physicians who feel in their considered 20 medical opinion that opiates are necessary to relieve this 21 chronic intractable pain. 22 Thank you. 23 MR. LEGARZA: Thank you, sir. 24 I'm looking to my right, and I see a lady and a 25 gentleman seated there. Page 10 1 Ma'am, do you have anything -- 2 MS. PRALL: No. 3 MR. LEGARZA: -- to present to the board? 4 Would you care at all to identify yourself for 5 purposes of the record? 6 MS. PRALL: My name is Jo Prall, P-r-a-l-l. 7 MR. LEGARZA: Are you a member of the general 8 public of the State of Nevada? 9 MS. PRALL: Yes. 10 MR. LEGARZA: And you're here simply because 11 you're interested in these proceedings; is that a fair 12 statement? 13 MS. PRALL: I suffer from chronic fatigue 14 syndrome and came to find out what, you know, what was knew. 15 MR. LEGARZA: Okay. Okay. Fine. 16 And seated next to you is a gentleman. 17 Do you have anything that you'd like to present, 18 sir? 19 MR. PRALL: No. This is my wife, and I have 20 watched her over the past 17 years now with this illness. 21 MR. LEGARZA: Excuse me. Would you mind 22 identifying yourself, sir? 23 MR. PRALL: My name is Harold Prall, P-r-a-l-l. 24 MR. LEGARZA: Thank you, sir. 25 MR. PRALL: And I am interested in how she's Page 11 1 going to -- we thought maybe this would help us and in 2 this -- with this pain. That's the only reason we're here. 3 We're just interested in it, that's all. 4 MR. LEGARZA: All right. Thank you, sir. 5 Other than myself and the court reporter, there 6 are, of course, two members of the media here, a gentleman 7 who was running the camera, and a lady who is taking notes. 8 Ma'am, do you have anything you would care to 9 present to the board at this time? 10 MS. CUNINGHAME: No, thank you, we're just here 11 to cover the story. 12 MR. LEGARZA: Thank you. 13 Unless anyone has anything else, and unless 14 anyone comes in, which I don't know that anyone will, this 15 matter will be -- yes, ma'am? 16 MS. DALY: I just had one -- something to add. 17 MS. RALKO: We're a little late because we 18 didn't know where the building was. 19 MR. LEGARZA: Okay. You may have a seat 20 anywhere that you think is convenient for you. 21 MS. DALY: She is with my group. 22 I wanted to add that on the way over here -- 23 MR. LEGARZA: Please re-identify yourself, 24 ma'am. 25 MS. DALY: I'm sorry, my name is Anne Daly. Page 12 1 MR. LEGARZA: Thank you, ma'am. 2 MS. DALY: On the way over here, they announced 3 on KNUR -- 4 MR. DALY: KUNR. 5 MS. DALY: KUNR that there will be a chronic 6 fatigue syndrome discussion on the radio on Sunday morning, 7 at -- 8 MR. DALY: 10:00 a.m. 9 MS. DALY: 10:00 a.m. Apparently this is 10 chronic fatigue week, or somewhere in this time frame, so, 11 it's timely. 12 MR. LEGARZA: Okay. For the benefit of the two 13 ladies that just came in, who had a hard time finding our 14 offices, we have been sitting here talking about what we are 15 doing here today, which is taking comments from persons who 16 may be interested in what the Nevada State Board of Medical 17 Examiners is doing with respect to promulgating regulations 18 to adopt the Federation Model Guidelines for Use of 19 Controlled Substances for the Treatment of Pain. 20 The four individuals who are in the room, the 21 two couples, if you will, have had the opportunity to give 22 the board the benefit of their thoughts with respect to how 23 they feel about what the board is doing or is about to do, 24 and we were just about to recess when you showed up. 25 So this is the time and place for anyone who is Page 13 1 interested in having the Nevada State Board of Medical 2 Examiners take into consideration their feelings or position 3 with respect to the adoption or lack thereof of these 4 federation guidelines to state for the record their position. 5 I would state to you that if you have something 6 to say, you may do so. If you have some documentary evidence 7 that you care for the board to consider or you have a written 8 statement that you care for the board to consider, you can 9 leave that with the court reporter and she will make it part 10 of the record. 11 If you have a statement to make, I would request 12 of you that you identify yourself, spell your name so the 13 court reporter can get it correct. You may want to say where 14 you reside, you may not. You may want to say what your 15 profession is, you may not. 16 And you may also indicate as to whether or not 17 you represent yourself or you represent a group or group of 18 persons or individuals who are interested in this process. 19 So if either of you ladies have any questions of 20 me, I will attempt to answer those questions, if not, if 21 either of you ladies have anything that you want to state for 22 the board to consider, which will be in this record here, you 23 may proceed. 24 And I'll -- you're sitting closest to me, so I 25 will ask you to go first, if you would care to make any Page 14 1 statements. 2 MS. AMENT: Well, being a patient -- 3 MR. LEGARZA: Excuse me -- 4 MS. AMENT: My name is Beverly Ament, and I 5 reside in Gardnerville. 6 MR. LEGARZA: Would you spell Ament for the 7 court reporter, please, ma'am? 8 MS. AMENT: A-m-e-n-t. 9 MR. LEGARZA: Thank you, ma'am. 10 MS. AMENT: Being a patient of fibromyalgia and 11 also have a lot of chronic pain, this is a good day for me. 12 I'm on disability, and any help in this area I am for it and 13 for anybody because I suffer daily. 14 And we're a group of women that gather together 15 in Carson City, what -- what do we call ourselves? 16 MR. DALY: Invisible Pain Group. 17 MS. DALY: Invisible Pain Group. 18 MS. AMENT: Yeah, these are women that get 19 together, and most of us are sick, that's why we're not here, 20 there's about ten -- ten of us, and we're there to uplift 21 each other. We know what each other are going through. 22 And we have a lot of trouble in trying to get 23 help from the doctors. I don't -- they just want to go so 24 far with you. I'm one of the lucky ones, I have an implant, 25 I have a computer disk in my abdomen, and it releases pain Page 15 1 medicines into my spinal cord. I have a needle that I walk 2 around with in my spinal cord. 3 And so I thoroughly believe in helping our group 4 or anyone else. This is the way I live, taking pain 5 medicine. 6 MR. LEGARZA: Thank you, ma'am. 7 MS. RALKO: My name is Arlene Ralko, R-a-l-k-o, 8 and I would like to say that we do present a balanced view 9 when it comes to treatment for pain. Beverly forgot to tell 10 you that she also has lupus, and that a lot of her pain is 11 caused from lupus as well. 12 What we want to do is present a balanced 13 viewpoint where we would like for physicians to try 14 everything possible other than narcotics to treat pain 15 problems. 16 But at some point, if that isn't working, we 17 would like physicians to have the freedom to prescribe pain 18 medication of a narcotic variety for cases where they've 19 tried everything else, they see that the individual has a 20 balanced personality, that they've observed the person and 21 realize that that person is genuinely in pain and is seeking 22 some sort of solution to their pain problems. 23 And we would like for physicians to feel like 24 they're not under the gun, so to speak, by the medical board, 25 or, as I read in the Reno paper this morning, the -- there is Page 16 1 a program that pharmacists use that alerts -- unfortunately, 2 I didn't get to read the whole article because I was pretty 3 busy this morning -- but that alerts the board that's 4 watching pharmaceuticals to the fact that someone might be 5 using narcotics excessively. 6 And what we want to eliminate is the pressure 7 off of the pharmacists as well as the physicians, but we also 8 have a balanced view, we would like people to consider what 9 the patient's personality is, whether that person is balanced 10 in their thinking before anything what I call stronger is 11 used for pain control. 12 And we try to present both sides, the doctor's 13 side and the patient's side when we're talking in our group. 14 And a lot of times I played the role of the physician and how 15 I would answer a patient that needs more medication. 16 And so I would say the bottom line is we wish to 17 allow physicians to have freedom to treat patients if they 18 need to without worry from the boards, either the pharmacy or 19 the medical. 20 MR. LEGARZA: Thank you, ma'am. I'm glad you 21 ladies found us. 22 MS. DALY: I am, too. 23 This is one of the bravest ladies in the world, 24 by the way. 25 MS. AMENT: I just wanted to comment, it took me Page 17 1 years to get help to -- I mean, I went through psychiatrists, 2 doctor after doctor after doctor screaming in pain and I kept 3 going to the emergency room. Nobody ever said I was addicted 4 to drugs. 5 I'm a very responsible person, and people that 6 take drugs should take them responsibly before driving and 7 out on the street. And I just think that people that are out 8 seeking the drugs they do get tolerance to the drug and they 9 need more to keep their level of pain, because that's what 10 happened with the pump. 11 The doctor has to adjust the pain medicine all 12 the time, and I have a pump implanted in me, and I will -- I 13 still have to take pills to cope. I have to hold onto the 14 cabinet to cook super, and -- and it's -- it's unreal how the 15 pain can be. 16 I have begged to be put in the hospital to my 17 husband, please just leave me there, and -- but I have to go 18 on with life. And so it just seems like a battle fighting 19 with the doctor and the pharmacist, does your doctor know 20 you're taking this many drugs. Yes, he does. 21 Well, we have to call before we can refill it, 22 we can't give it to you. It's three, four days before your 23 drugs are due. So we want to have a level of balance there 24 between the pharmacist and us and the doctor. 25 MR. LEGARZA: Is that it? Is that all, ma'am? Page 18 1 MS. AMENT: Yes. 2 MR. LEGARZA: Okay. Thank you. 3 Oh, I guess now we can adjourn. Do any of you 4 folks expect any friends or associates to be showing up here 5 who have not yet arrived? 6 MR. DALY: The Reno fibromyalgia and -- oh, you 7 are the Reno group. 8 MS. AMENT: Uh-huh. 9 MR. DALY: Oh, okay. Delete my comment. 10 MR. LEGARZA: Okay. 11 MS. DALY: This is fibromyalgia, chronic 12 fatigue, post-polio syndrome, lupus, and -- 13 MR. LEGARZA: One at a time. 14 MS. DALY: My name is Anne -- 15 MR. LEGARZA: And you need to identify yourself. 16 MS. DALY: My name is Anne Daly. 17 And included in just our small group, we're sort 18 of a mixed bag, rather than not only chronic fatigue, we have 19 across the board, we've lost several of our members because 20 they're just too -- they can no longer navigate to get there. 21 They're too sick, most of them do not have proper medication. 22 It's just very difficult to absorb. 23 And I started with this group two years ago and 24 have watched them and how their dignity is intact, they 25 always -- they always look great, no matter what, they get Page 19 1 out of bed and do what they have to do and they don't 2 complain. 3 I mean, we do get a lot of complaining done at 4 the group where it's -- that's what it's for, and get -- to 5 get the moral support and suggestions. 6 And, for instance, this lovely lady brings this 7 lovely lady when she needs to go somewhere. If she's in pain 8 and needs to go to the doctor, she fell the other day, Arlene 9 went over and picked her up, took her to the doctor, to the 10 hospital, back to the doctor. 11 And so the idea of a support group I think is -- 12 this fulfills it in every way. I think it's a wonderful, 13 wonderful idea. They are working -- you know, they are not a 14 work in progress. They're well and firmly established, and 15 if anybody needs help, they ought to get on the horn and find 16 out where they can be treated or at least psychologically 17 uplifted for the time being. 18 Thank you. 19 MR. LEGARZA: Thank you, ma'am. 20 MR. DALY: I also -- Terence J. Daly -- I'd like 21 to just add to my earlier statement, about the need for 22 doctors, and as Ms. Ament has brought up, pharmacists to have 23 a safe harbor should they feel it medically necessary to 24 provide an opiate pain medication. 25 And at one of the meetings a couple of years Page 20 1 ago, mention was made at one of the meeting participant 2 doctors having received what they call a $10,000 letter. 3 That's a letter from the State Board of Medical Examiners 4 that the doctor -- it will cost the doctor about $10,000 to 5 answer that letter and clear the doctor's name for over -- 6 allegedly overprescribing opiates. 7 I would hope that these model guidelines, the 8 national model guidelines would protect doctors from 9 receiving those $10,000 letters. 10 MR. LEGARZA: Okay. Thank you all for being 11 here. Your comments will be transcribed by the court 12 reporter and the members of the Nevada State Board of Medical 13 Examiners will have the benefit of your thoughts prior to the 14 time they make a determination as to whether or not they're 15 going to adopt the guidelines by reference. 16 You don't have a copy of the guidelines, did you 17 get a copy of this? 18 MS. AMENT: Yes. 19 MS. RALKO: This is -- is this a double set? 20 MS. AMENT: Yeah. 21 MR. LEGARZA: I have more copies if any -- if 22 you would like to take -- 23 MS. AMENT: I have part of the information. 24 MR. LEGARZA: If you would like to take some of 25 these back to your group. Page 21 1 MS. AMENT: Yes. 2 MR. LEGARZA: I can give you -- I have many more 3 copies. I can -- would you like me to give you some more? 4 Thank you. We'll be in recess. 5 MS. DALY: Thank you. 6 ---o0o--- 7 8 9 Page 22 1 STATE OF NEVADA ) ) ss. 2 COUNTY OF WASHOE ) 3 I, Karen Bryson, a notary public in and for the 4 County of Washoe, State of Nevada, do hereby certify: 5 That at 11:00 a.m., Friday, March 31, 2000, at 6 the Nevada State Board of Medical Examiners, 1105 Terminal 7 Way, Reno, Nevada, I was present for the above-entitled 8 matter; 9 That said workshop was taken in stenotype notes 10 by me, a Certified Court Reporter, and thereafter reduced to 11 writing by means of computer-assisted transcription as herein 12 appears; 13 That the foregoing transcript, consisting of 14 pages 1 through 21, is a full, true and correct transcription 15 of my stenotype notes of said workshop, to the best of my 16 skill, knowledge and ability. 17 Dated at Reno, Nevada, this 3rd day of April, 18 2000. 19 20 ______________________________ 21 Karen Bryson, CCR #120 22 23 24 25 Page 23