Doctor Killed For Not Prescribing Pain Pills To Patient

August 7, 2017 / Thomas Cohn, MD

Last week one of my colleagues in the Pain Medicine community was shot and killed for not writing an opioid prescription to a patient. I was sent an email from a manager who came across the information in passing, and I was shocked at the incident.

The worst part of this incident was that the victim and colleague was once a medical student and then a medical resident with me while I was in training. I have not kept in touch with him but he was an excellent doctor and a caring individual. Unfortunately, that did not matter to the person who killed him. The only thing they understood was he did not feel it was indicated to prescribe opioids, which in retrospect was clearly the right choice.

Addictions and Opioid Dependence

Pain management and treating pain has always been more than prescribing medications like opioids. Anyone who has read this blog knows my field is all about how complex treating pain has become. If you as a patient believe that the only thing you can do for your pain is taking opioids, you likely have an issue with addiction that is far beyond just managing pain.

Addiction is a psychological problem and one does irrational things to obtain whatever substance you want for the dopamine support. The things one would do are beyond societal norms and are often illegal. The problem is not only about pain; it is about how to manage the addiction. There are countless ways to manage pain and unfortunately there often is not a cure. Pain management clinics are faced with the problems of opioid use every day and one of the most important jobs we have is to find other options beyond these medications to help patients. There is a shortage of professionals who have the training and ability to work in this challenging area, and it is tragic that someone has lost their life doing the right thing.

Alternatives To Opioids

Having pain is a common occurrence in this world. Worldwide about 30 percent of the population has problems with pain on a regular basis. The use of opioids to solve pain problems has become an American solution. The United States uses 95 percent of the narcotics produced in the world, yet we are only 5 percent of the world’s population. If your doctor is saying no to opioids, there usually is a good reason, and working with a specialist to find a better solution is indicated. Most people, once they develop significant neck or back issues, will not be pain free, but one needs to make some life changes to control the symptoms. Pain is a tough medical issue and the United States does have an opioid epidemic.

If it is upsetting that there are not better treatments for pain, become vocal about this problem. Start with your insurance company and with your legislators and make it known you want money to be spent on paying for more treatments for pain. Money is being spent on addiction but one of the more important issues is spending money on treating the pain problem before it becomes an addiction. Pain is a grueling and depressing part of life. There are hundreds of pain professionals trying to make life better for those suffering with pain, please do not let your anger out on them.

The Benefits Of Being An “Old School” Doctor

August 1, 2017 / Thomas Cohn, MD

Since I have been in practice, medicine has changed drastically over the years. Technology and improved practice standards have given way to great changes in the care of patients. When I first started in medicine, there were no electronic charts, most notes were handwritten, and computers were not a standard part of practice. CT scans were relatively new and the MRI scan was not yet invented. Medical students were trained to do a comprehensive history and then a physical exam. Part of the history had to include a detailed account of how the condition the patient has had developed over time. Another part was a detailed exam, including looking at the patient, often with minimal clothes obscuring the body. These are very simple things – listening to a story and looking at the patient.

Unfortunately, many doctors have lost the skill to be able to evaluate a patient. Oftentimes the patient has a classic story to tell and it fits exactly to a particular medical problem. Just spending a couple of minutes listening and asking some questions will lead you to the solution, and it probably matches a common or uncommon medical problem. After many years in practice, looking and listening to a patient tells most of the story of what is wrong. Adding a physical exam will fill in the missing parts most of the time. The fancy diagnostic studies usually are a confirmation of the problem.

Relying On Technology

Many doctors are now trained using technology. The patient history is on the computer and the first thoughts are what do the studies indicate. If the picture (imaging) shows problems, then that must be what is wrong. Treating a test or picture can be okay, but the body has a remarkable way to adapt to changes, and the true problem is usually more complex then the picture and the way to navigate to a solution is to stop and ask the patient what is wrong, then correlate to an exam and picture.

Last week being old school paid off. A new patient showed up at my office frustrated that she had years of pain and no explanation. The patient had been everywhere, including the Holy Grail –The Mayo Clinic – and still no answer on what was wrong. The patient did have a confusing history, but it was important and the details gave the clues. Watching the patient walk and looking at her legs and arms was truly remarkable. The patient was in her 20’s and was significantly weak with loss of muscle bulk.

She had a significantly abnormal exam and likely had a serious muscle and nerve disorder. If the previous physicians only took the time, they would have figured out there was a problem and could have guided the patient towards better solutions years ago. Now, hopefully the patient can get the right diagnosis and help. It may take time and a few more tests, but an answer can be found. One of the best skills a doctor can have is the ability to listen and look at a patient. It is simple, but medicine has changed and doctors are rarely paid to take the time to do the basics.

5 Things People With Chronic Pain Want You To Know

July 20, 2017 / Thomas Cohn, MD

Living with chronic pain is difficult enough before you add in the stigma you have to deal with from other people. Hopefully your friends and family members are sympathetic to your condition, but even they don’t fully understand what you’re going through. Today, we want to share five things that people with chronic pain want you to know about their condition.

What We Want You To Know

Here are five things that patients with chronic conditions wish others knew about their condition.

We don’t want to be in pain

This may sound obvious, but sometimes people think individuals are just playing up their pain to get attention. Trust me, they’d trade all the attention in the world if they could live a pain free life. If they are talking about their pain, it’s because they want you to try and understand what they’re going through, not because they are craving attention.

Just because we don’t show it, doesn’t mean we’re not in pain

We put on a brave face and go about our daily life, but just because we’re smiling doesn’t mean we’re not in pain. Chronic pain patients often try to mask their pain because they don’t want to be seen as weak or injured, and some are great at hiding their pain. But that doesn’t mean we don’t feel it with each step.

Keep reaching out

It’s impossible to predict when a flareup is going to occur, so if we say we can’t make it out to the mall or we cancel on movie plans at the last minute, we’re not trying to avoid you. We’re just dealing with a lot of pain and we’d be miserable, but we love that you’re reaching out. Keep texting and calling us, because we really do want to hang out. Don’t assume that we’re intentionally trying to avoid you, because we’re not.

We’re not in it for the drugs

We don’t want to be taking pain pills, but sometimes they are the only thing that makes it bearable to get through our physical therapy session. We’re not just popping pills and hoping the problem gets better, we’re actively working towards finding a solution through a combination of therapy techniques.

We’re not lazy

What’s easy for some is a huge burden to others. When chronic pain is at it’s worst, even getting out of bed in the morning can be difficult. Again, we’d trade anything for the chance to live without constant pain, but life doesn’t work like that. We’re not using chronic pain as a way to get out of work or doing chores. We’re trying our best, even if it doesn’t look like it.

Overprescribing Opioids Is A Problem In Our Own Backyard

July 13, 2017 / Thomas Cohn, MD

New findings published in the Annals of Surgery suggests that clinicians at the Mayo Clinic in Rochester were routinely writing opioid prescriptions for surgical patients that exceeded regulatory guidelines currently being drafted by the state of Minnesota. The findings also uncovered significant differences in opioid prescribing among the Mayo clinics in Rochester, Arizona and Florida, as well as within surgical procedures.

Study senior author Elizabeth Habermann, who also serves as the scientific director of surgical outcomes research at Mayo, said the findings help highlight where improvements can be made.

“In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve,” said senior author Elizabeth Habermann, scientific director of surgical outcomes research at Mayo. “This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient.”

Opioid Overdoses In America

According to the Centers for Disease Control and Prevention, the number of deaths involving prescription opioid overdoses have nearly quadrupled since 2000. In fact, more than 90 people died each day from either a prescription opioid or heroin overdose in 2015 alone.

Study co-author Dr. Robert Cima said doctors have been so focused on ensuring patients have their pain minimized as much as possible after surgery that they often don’t consider the possible long-term side effects of the prescriptions they’re filling.

“For the last two decades, there had been such a focus at the national level on ensuring patients have no pain,” said Dr. Cima, a colorectal surgeon and chair of surgical quality at Mayo Clinic’s Rochester campus. “That causes overprescribing, and, now, we’re seeing the negative effects of that.”

I have no doubt that the Mayo Clinic will adhere to the new guidelines being drafted at the state level in short order, but this story speaks to the larger issue of just how unregulated opioids are at some of the nation’s best hospitals. And if it’s happening there, you can bet it’s happening to a larger degree at lesser care centers.

However, these findings do cast light on the problem and should help push us towards a solution, but it’s not necessarily going to come from the top down. It needs to start with doctors. We need take time with each patient and push them towards active treatment techniques instead of passive treatments like opioids. Opioids certainly have their role in pain management, but they shouldn’t be over-relied on, as it appears they are.

Why Are We Treating Pain The Same As We Did During The Civil War?

July 4, 2017July 4, 2017 / Thomas Cohn, MD

It is no secret that there is an opioid problem in the United States. It seems like there is a new report being published every week on the problems with opioids in this country. This week the government published data on the number of emergency room visits related to opioid use in a single year.

The data shows roughly a 100 percent increase in the last ten years in the number of hospital visits and admissions related to opioid problems. Not surprising is that despite some differences from state to state, in general, the problem affects everyone equally – male and female, rich and poor – just like any other addiction. The focus of most data being published is on opioid addiction. Unfortunately, rarely is someone talking about some of the reasons behind the problem, especially as it relates to how the United States treats pain.

How The US Treats Pain

It is really no surprise that there is an opioid problem in the United States. Pain is a very complex set of medical issues, but unlike diabetes or cancer, very little money has been spent on any aspect of pain as a medical problem, and medical school and physician training in understanding and managing pain is virtually nonexistent. Research sponsored by any government or industry sources is minimal compared to all other areas, maybe 2 percent of all money spent by the National Institute of Health and there is no comprehensive strategy to look at treating pain. Most importantly, the tools used to treat pain are the same tools we used at the time of Civil War – opioids. Most other diseases from hypertension to diabetes and cancer over the last fifty years have seen major advancements in how we treat these conditions, but not pain.

On top of the publishing of new data of how many people are being affected by opioids, the news media is full of sensational information on every aspect of the opioid epidemic. Time magazine this week had information on how drug companies and drug treatment centers are profiting from opioid problems. One of the biggest lobbying groups for money and guidelines on opioids are addiction specialists and drug treatment centers; just a slight conflict of interest. Then the sensational news moves to all the individuals who have become addicts and the problems of addicts. Unfortunately, opioid addiction and how it affects individual lives is not really significantly different from other addictions from food to alcohol, it’s just less glamorous. The latest highlight in the news is the potent drugs and overdoses, and how just touching some of these illegal drugs or using for the first time can cause overdoses.

Opioids are a problem in the United States and more data does not help solve the problem – it just makes it sensational. The real issue that is being ignored is the issue behind opioids and how we treat pain. Most of the pain treatments available date back to before the Civil War. Pain is extremely complex, and to solve the opioid issue the United States needs to get serious about finding better pain management tools and invest in them.