Physicians are fearful of fulfilling their duty to treat pain

I recently testified before the Medical Licensing Board of Indiana regarding the pending emergency rules for physicians prescribing opioids for chronic pain. The session went on for four intense hours — ten minutes of which had been promised to me.

At my turn, I stated my name, told the Board I hailed from from Indiana’s prescription ground zero, gave a brief summary of my credentials, thanked the Board, the American Academy of Pain Management, Lelan Woodmansee (our Greater Louisville Medical Society Executive Director), my staff for working to free me up to come, and most importantly my patients who had been rescheduled to allow time for my trip to Indianapolis.

I explained how Kentucky’s new pain regulations had borrowed language from the Federation of State Medical Board Guidelines but had changed most of the flexible language (ie. “may” and “can”) to inflexible language like “must” and “shall”.

I opined that prosecutor-types prefer inflexible “black and white” language that makes it easier to define a violation. And that Kentucky’s voluminous regulations had motivated many physicians to simply give up on treating pain.  And that Indiana should embrace their opportunity to create regulations that would address drug abusers without harming the innocent.

I said in the interest of time I would limit my comments to three areas:

  1. The threshold for increased surveillance and boundaries;
  2. Preserving the collaborative health care team; and
  3. Proper utilization of drug screens.

Then a chill went through me as the Board president looked up from his laptop and said: “You have one minute left.”

One minute?

I composed myself and tried to get across my three points as fast as I could.

1.  I recommended that the regulations kick in when a morphine equivalent dose of more than 60mg per day at any time during three consecutive months is prescribed – as opposed to the draft’s threshold of 15mg per day for three consecutive months.

2. I explained that colleagues (including APRNs) often share on-call responsibilities, clinic coverage, and the daily care of their practice’s patients. I recommended that, rather than requiring each physician do his or her own detailed initial evaluation, instead:

The initial evaluation of a patient covered by these regulations must be by a provider licensed to prescribe controlled substances. Other providers within the same group who share the responsibility to care for the patient are not required to perform their own separate initial evaluation if they accept the original initial evaluation as clinically adequate and in compliance with this regulation.

Unfortunately my ten minutes expired before I could get to the drug screens.

3. I wanted to ask that the regulation requiring urine drug testing be modified to give deference to the prescriber’s clinical judgment with respect to laboratory analyses used to assess compliance:

At the outset of an opioid treatment plan, and at least annually thereafter, a patient’s evaluation shall include a laboratory analysis to aid in determining compliance with the prescribed plan of care, with consideration of confirmatory laboratory analysis if necessary.

Not to worry.  The Board president invited me to come back at the end (approximately 2 hours later) and finish my comments.

Two hours later I was told I could only have 90 seconds.

Seriously?

With so little time to make a final impression, I decided to make this personal.

I showed each Board member an iPhone picture of the crumpled pile of metal that only two days earlier had been my daughter’s car. Thankfully she survived the horrific crash but had sustained several contusions and a fractured arm. After being strapped to a board, transferred by ambulance, x-rayed and evaluated in the ER, she had been discharged with a prescription for ibuprofen.

Ibuprofen.

Pulling some strings, I was able to get her in to see an Orthopedist the next day. He reassessed her injuries, casted her broken arm, and told her to stop ibuprofen. Take only acetaminophen.

Acetaminophen.

Moments before my final ninety second plea to the Board, my daughter had texted that she was in severe pain. Breathing was excruciating.

“Daddy, can you do something?”

My daughter’s suffering was due to the pall of fear Kentucky’s new pain laws had cast over her physicians.

Her mother called our family physician’s office. Thankfully, a provider did come to my daughter’s rescue, phoning in a prescription for a mild opioid pain medicine.

Ironically, this was the only provider who had not personally examined my daughter.

The only provider who was not subject to the massive regulations of the Kentucky Board of Medical Licensure.

A provider who was not afraid to treat my daughter’s pain.

Not a physician.

A nurse practitioner.

As I concluded my ninety second wrap up, I challenged the Indiana Board to create regulations that will not make physicians fearful of fulfilling their duty to treat pain.

The Board adjourned, and I waited to see if anyone wanted to speak with me.

No takers.

I hope my ten minutes and ninety seconds were effective.

I hope the future allows a few more minutes to get this right.

James Patrick Murphy is a physician who blogs at The Painful Truth. He can be reached on Twitter @jamespmurphymd.

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  • http://ClinicalPosters.com/ ClinicalPosters

    It hurts me to read of your daughter’s pain. Hopefully your testimony will resonate.

    • James Patrick Murphy, MD, MMM

      She is doing quite well now, thanks.

  • James Patrick Murphy, MD, MMM

    Thank you Dr. Pho, for shedding light on this.

    If anyone wants to help, they can contact the Medical Licensing Board of Indiana c/o: pla3@pla.IN.gov and ask them to support the recommendations of Dr. James Patrick Murphy of Jeffersonville.

    Ask them for regulations that do not make physicians fearful of treating pain.

  • Suzi Q 38

    That is really bad.
    I was given Norco #60 with 2 refills for an arthroscopic knee surgery.
    Ditto for my cervical spine surgery and hysterectomy.

    The first few days I needed the meds, but after that, I weaned myself off the meds. I did not need refills. I still have tablets left.

    Ibuprophen would no be enough after the injuries that you describe your daughter had.

    I am glad that an NP was able to get your daughter some stronger meds.

    Not everyone that needs these stronger drugs becomes addicts.

  • Melissa Travis

    Thank you for sharing this. I went through an awful time when I moved states and my new doctors didn’t have the same “trust” with me (in addition to new laws). I’ve learned to suck up a lot of pain. And also – I’ve learned that the only thing less treatable than pain are attitudes and fear.

  • GT

    “But assuming that everyone with a painful condition needs/wants opiates is just as dangerous…”

    I missed the part where the author advocated for handing out opioid analgesics like lollies. His daughter had been in a serious car smash, and sustained painful injuries that neither acetaminophen nor ibuprofen were helping. “[M]y daughter had texted that she was in severe pain. Breathing was excruciating.” This is exactly the time-limited kind of injury-related acute pain that opioids can be very helpful for, and treating an ordinary patient with no prior mental health or addiction issues with opiod analgesics in circumstances like this is actually not very likely to suddenly turn her into an addict.

    When patients with acute injuries are left in excruciating pain, it really can cause more harm than good. A patient left in severe unremitting pain will probably not be breathing properly, will not be eating properly, their immune system may be weakened, and they will definitely not be getting enough of the rest their body needs to heal properly. You say that you see the effects of HCPs who you believe should have “been a little more reluctant to prescribe opiates”, and I don’t doubt that. But there are also victims out there of HCPs who have been TOO reluctant to prescribe opioid analgesics. Their presentation just isn’t as dramatic or the cause of their problems as obvious. But they’re just as real.

  • GT

    My mother is a veterinarian who worked on a study looking at inadequate pain relief for small mammals (cats and dogs). It’s absolutely accepted now that many vets had been severely undertreating pain in pets, and that that had been causing actual physical delays in healing. I understand that pets don’t face the same issues of addiction as humans do, but I also am of the belief that addiction (as opposed to dependence) is a mental health issue, and it’s hard to ask all doctors to undertreat all patients just in case one of them might have an underlying undiagnosed mental health issue that would predispose them to addiction.

    Anyway, the veterinarians at the University of Wisconsin
    Veterinary School are proponents of ensuring adequate pain control for pets. They point out that the “benefits include improved respiratory functions, decreasing stress responses surrounding surgery, decreased length of hospitalization, faster recovery to normal mobility, improved rates of healing and even decreasing the spread of cancer after surgery. Almost all studies show people and animals return to normal eating and drinking habits sooner when given relief from pain. Therefore prevention, early recognition and aggressive management of pain and anxiety should be essential to veterinary care of small mammals. The current approach is to be sensitive to the subtle signs of pain, because the treatment of pain itself can be healing. Pain is stressful and can prolong recovery.”

    With humans as with animals, doctors who withhold adequate pain relief from patients recovering from injury or trauma are doing those patients no favors.

    • meyati

      A speeding car tire threw a piece of gravel. It hit my Bluetick’s thigh. I checked him, he didn’t limp or flinch. The next day there was a small bump. The next day, it was humongous. He kept coming to me, and wagging his tail. We went to the vet. He had biopsies to make sure everything was OK, and quality care. Antibiotics, but no pain killer. The next morning he put his head in my lap-then touched his nose on the blood blister. I called up the vet and said that I was coming in for pain killers. When she asked why, I said that he told me he hurts a lot- He got his pain killer. Every time I got the pill bottle out, he wagged his tail.

      Maybe the other dogs don’t communicate so well-but everyone that has had a blood blister complains about the pain-how can a vet not think that the hound didn’t hurt. Sure he didn’t whine when it was touched, sure he didn’t limp-but everyone knows that most animals hide their pain. If he didn’t have pain killer, he probably would have started chewing on it. While humans don’t chew on bad knee or try to hide it, they still hurt and have difficulty with mobility.

      Me, I have difficulty in getting anything for pain like my arm jammed into the rotator cuff. I dread getting anything for chronic pain.
      Hint: Before you schedule an in office surgery-ask if the surgeon is scared of the DEA-It’s not like they have very many chronic pain patients.

      • GT

        You are right, growing up with two Veterinarians for parents, I was around animals a lot. Animals absolutely hide their pain, and for good reason: it’s an evolutionary trait. Obviously-weak and obviously-injured animals become prey very quickly, either by their natural predators or even from their own herd or pack because they will slow it down. Animals that were good at hiding injuries survived. I am glad you took such good care of your dog. I hope that you can find a doctor who will treat you with such good care.

  • Tiredoc

    15 mg of Morphine equivalents a day? What’s the point of that? The data speaks to an increased rate of sudden death for 100 mg/day, and even that’s an artificially low number due to the usual statistical muddle of retrospective analysis. We’ve gone from “pain is the sixth vital sign” to “demon morphine” in less than 10 years.

  • SarahJ89

    My experience was the opposite. The MDs in my area hand out oxycodone and vicodin on next to now acquaintance like they’re sugar candy. I ended up with two scrips for a total of 50 pills I never even filled. I could have easily sold them to my prescription-drug addicted neighbour. No one asked if I wanted or needed these pills, by the way. They were actually useless. Taking enough to do anything for the pain meant my mind and body were trashed.

    Here’s what I could have used: actually treatment for my broken arm. Instead I was left to languish for a week with an unset broken arm in an increasingly floppy splint because of “scheduling problems.”

    Here’s what my neighbour could have used: treatment for the injured shoulder that started her chronic pain problem. But she’s one of the many without health insurance so she now is one of the many we can all look down our noses at.

    I’ve worked with a lot of people with chronic pain. Their experience is pretty dismal in other ways.

    The suggestions made by the author sound like a reasonable beginning. What’s going on now doesn’t seem to be working for anyone.

    • Suzi Q 38

      I will have to agree about no one asking if I needed the drugs (in my case Vicodin and Norco). I think that a week or two after a surgery would have been sufficient for me. I used Tylenol during the day, and Norco at night. I slowly weaned myself off after 3 days or so. By week 2, I was finished with the drugs and using OTC meds. I did not need the 1 and 2 refills that my doctor ordered for me. I appreciated it, though.

      Everyone’s pain is different and should be treated as such.
      I could have sold my extra, too. A friend recommended that I do so, and I have since hid my bottles from her or anyone else that wants them, LOL.

      • SarahJ89

        Yes, I want to make it clear I did not sell them. My neighbour does not need me adding to her problems.

  • buzzkillerjsmith

    A while back we had a presentation in the clinic about treating chronic pain with opioids here in WA. it was something straight out of Monty Python, the hoops you have to jump through are so numerous and arbitrary. So very few regular docs are going to do it. I think it was because the chronic pain docs don’t want any business taken away but I’m not really sure.

  • ninguem

    Do you not see a problem with allowing one standard of care for one group of practitioners (ARNP’s), and another for MD/DO’s?

    What would you think of a physician who prescribed a controlled drug to someone who had not been seen or examined?

  • Cyndee Malowitz

    Granted, you daughter needed more than just Tylenol or ibuprofen for the pain. However, the majority of people taking narcotics, at least in the U.S., do NOT need a narcotic for their pain. According to ABC News, “The U.S. makes up only 4.6% of the world’s population, but they consume 80% of it’s opioids.” Pretty amazing.

    I used to work in pain management and several patients told me they were still in pain even though they were taking long-acting narcotics with short acting narcotics for breakthrough pain, but they were too wasted to care.

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