Doctor Killed For Not Prescribing Pain Pills To Patient

pills doctor killedLast 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

old school doctorSince 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.

Cutting Back On Opioids Could Reduce Pain

opioids cutting backIt may sound counterintuitive, but new research suggests that reducing long-term opioid intake could actually lead to lower pain levels in patients with chronic pain.

More than 10 million Americans are currently prescribed a long-term opioid to deal with a chronic pain condition. The number of people who get these prescriptions continues to grow, and not surprisingly so too do opioid overdose deaths. Used correctly, opioids can work wonders for individuals who have been struggling to find a way to take control of their chronic pain, but far too often they are overprescribed and knowingly or unknowingly abused.

Long-term opioids should only continue to be used if you’re still seeking active treatment options to address the painful condition. Since opioids are a passive treatment option, they are only masking the pain, and they aren’t actively working to correct the problem. They can work wonders when paired with active solutions like physical therapy or exercise because it can lessen pain during these crucial strengthening times, but if you’re not actively working towards a solution, long-term opioids are just dulling the pain while your body begins to crave larger doses of the drug to be effective, which can lead patients down the path of addiction.

Reducing Long-Term Opioid Intake

Researchers conducted a systematic review of 67 published studies in order to determine the effects of discontinuing long-term opioid therapy for patients with chronic pain conditions. Although they admit that the overall quality of evidence was not superb, they found an association between long-term opioid dose reduction and improvements in pain, function and quality of life.

“It’s counterintuitive that pain and well-being could be improved when you decrease pain medication…but patients felt better when dosages were reduced,” said Dr. Erin Krebs, medical director of the Women Veterans Comprehensive Health Center, part of the Minneapolis Veterans Affairs Health Care System, and an author of the study.

However, study authors echoed what we’ve been saying in this blog, that long-term opioid reduction shouldn’t be done by itself. It should be reduced with the oversight of a licensed physician and paired with other multidisciplinary approaches and behavioral interventions to continue actively pursuing pain reduction and function improvement. Hopefully future studies can take a closer look at this idea and provide some clearer solutions with stronger evidence so we can continue doing everything in our power to help patients fight back against their chronic pain conditions.

Overprescribing Opioids Is A Problem In Our Own Backyard

opioid problems mnNew 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.

Could We Be Pain Free In The Future?

mouse vaccine painAlthough not as much money is being spent on understanding pain as doctors would like, there is still some promising research taking place throughout the world. For example, new research published in Nature Neuroscience took a closer look at re-wiring the brain’s transmitters when it mistakenly interprets signals as pain.

The research began by looking at mice who had peripheral nerve damage and chronic pain from a previous leg surgery. In these mice, a broken circuit in the pain-processing region of the brain caused hyperactivity that led to pain for more than a month. Scientists realized that the peripheral nerve damage deactivated a set of interconnected brain cells, called somatostatin (SOM), which usually work to lessen pain signals.

Fixing The Broken Circuit

Researchers were interested in learning if this connection could be fixed, and if it could, how we’d go about repairing it. One method they tried was to manually activate the SOM interneurons, and they found that this led to a significant decrease in the development of chronic pain.

“Our findings suggest that manipulating interneuron activity after peripheral nerve injury could be an important avenue for the prevention of pyramidal neuron over-excitation and the transition from acute postoperative pain to chronic centralized pain,” the authors, led by neuroscientist Guang Yang at New York University School of Medicine, conclude. They believe future drug therapies or magnetic brain stimulation could mend these SOM interneuron connections and prevent pain signals from misfiring.

The authors are cautiously optimistic, but they realize that there is a big difference in the brains of mice and the brains of humans. The study needs to be repeated and the results verified before any similar testing in humans could take place, but it’s a start.

“Our study provides, to our knowledge, the first direct evidence that impaired SOM cell activity is involved in the development of neuropathic pain,” the researchers wrote.

They hope to confirm their results and examine whether manipulating other cells could play a role in the reduction of chronic pain. If they can, we may have specific cells in which to base our intervention techniques. This is exciting.