Intimidating doctors won’t solve the chronic pain epidemic

Nearly every day we read headlines about the serious prescription drug problem in America.  Increasing heroin addictions and deaths from illicit drug use are taking a severe toll on far too many families and communities. While we must feel enormous sadness for the families experiencing these tragedies, we must not overlook the other major health crisis that is often associated with the opioid abuse problem: chronic pain.

The chronic pain crisis in America receives far too little dialogue and education in the medical establishment or coverage in the press. The 100 million Americans who suffer some type of ongoing, persistent pain, according the Institute of Medicine, often face a frustrating and dehumanizing search for medical professionals who can help them. They find themselves set adrift in a healthcare delivery system that does not reimburse appropriately for evidence-based, alternative therapies and treated by clinicians whose medical training lacks even the most basic instruction on managing pain.

Fixing all of this takes time, commitment and — most crucially — money for research and education, all of which fall short. Meanwhile, prescription drug abuse and opioid drug-related deaths are a full-fledged epidemic. Drug overdoses have tripled since 1990 with prescription drugs as a driving factor. More than 12 million people reported using prescription painkillers (i.e., opioids) without a prescription in 2010, and emergency department visits have skyrocketed in recent years also.

To combat these tragic numbers, unfortunately, the legal system’s strategy has become prosecution of doctors who treat patients using opioid analgesics, even when criminal intent on the part of the prescriber is indisputably absent. I served as an expert witness in one such recent legal case that clearly stands as an example of prosecutorial overreach.

Accused of involuntary manslaughter in multiple deaths in his Des Moines, Iowa, practice, Daniel Baldi, DO, was, thankfully, cleared of any wrongdoing when the judge dismissed two of the nine charges, citing lack of evidence, and the jury acquitted on the remaining seven charges.

Testimony in the trial, far from proving the prosecution’s contention that the doctor’s reckless prescribing led inevitably and predictably to the deaths, instead revealed that the decedents died from a variety of causes and contributing factors that included worsening medical conditions, the use of medications not prescribed by Baldi, and the abuse of illicit substances. Tragically, Baldi is financially ruined and professionally scarred, and the legal system offers no recourse for such injustices. Prosecutors can levy charges that ruin careers without any accountability.

My colleagues and I at a former Salt Lake City, Utah, pain clinic have also dealt personally with the tragedy of patients who die, not as a result of treatment, but in spite of it. The Drug Enforcement Administration (DEA) opened an investigation related to overdose deaths at the Lifetree Pain Clinic, beginning with a raid on the clinic in 2010.  After nearly four years, the U.S. Attorney for the District of Utah declined to pursue charges and the case was dropped.

Yet the ripple effects of such actions are felt in the medical community, as practitioners reduce their willingness to prescribe strong medications, even when they are indicated. Why take the risk of taking the blame when a patient dies of any cause? This is sad reasoning indeed.

There is torment in the dilemma between treating patients to help them escape excruciating pain and running the risk of being targeted for prosecution if, in some cases, under specific circumstances, the treatment plan involves opioids. The dilemma is worsened when one realizes how close is the link of chronic pain to suicide.  The scientific literature tells us people with chronic pain are at two to three times the risk of others for suicide.

Regardless, most of the focus is on enforcement measures. A recent report in the New York Times cites a 23% decline in overdoses in Florida, crediting policies and enforcement measures implemented to address the state’s overdose crisis. The elimination of “pill mills” in Florida using enforcement should be applauded as these mafia-like clinics were not remotely legitimate providers of care.

However, because policies and enforcement were necessary and effective in Florida does not mean aggressive enforcement tactics are the most effective methods to address the problem of drug abuse or overdoses elsewhere. Reasons for abuse and overdose are multi-factorial and to think that more aggressive law enforcement or regulations will solve the problem is short sighted if not harmful to our communities and particularly to people in pain who are increasingly struggling to find someone to treat them.

Furthermore, the report dismissed the dramatic overall reduction in overdose deaths in Utah (approximately 33% from 2007 to 2013), which ignores a potentially more effective and sustainable approach to preventing harm. The Utah approach was not centered on policies and enforcement but education. We must not forget the real problem is how to treat chronic pain safely while preventing harm from opioids.

Opioid medications are not the only or the best therapy for all patients or all types of pain. They clearly bring risk and should be reserved for those patients who truly need them, administered by clinicians with the training and will to assess and monitor patients in accordance with accepted medical guidelines.  However, every patient with chronic pain should have access to a minimum level of insurance benefits and, for some patients and some pain conditions, that includes opioids.

To safely treat the largest health care problem in America, chronic pain, our society must not react by limiting access to medications. A system that intimidates doctors and refuses to fill prescriptions, which is happening at some corporate pharmacies, ultimately leads to patients suffering from debilitating pain, isolated and desperate.  Paradoxically, patients for whom medical options are limited are being abandoned, forcing them into hopeless circumstances. Along with a commitment to find better therapies and better access to them, we need to change our attitudes, by providing these patients — and their doctors — with the dignity of care equal to that accorded other chronic illnesses.

Lynn Webster is medical director, CRI Lifetree and immediate past president, American Academy of Pain Medicine. 

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  • doc99

    Government is not the solution to the problem. Government is the problem. Ronald Wison Reagan

    • miller1975

      T. Boone Pickens advice to the government for solving our oil dependency problem was- what we need first is a major public crisis; then, the government has no choice but to takeover.

      Seem oddly familiar?

  • ninguem

    Whatever happened to that Dr. Weitzel, the psychiatrist in Utah, who got caught up in a case like what you describe here?

    I know the Weitzel case got coverage on “60 Minutes”

    • Matthew Durham

      There is a lot going on in alternative care for chronic pain. I think that will become part of the answer.

  • DeceasedMD

    I think the sad fact is these are the hardest cases to often diagnose and treat. It often requires a lot more time and they are often shunted or ignored because it is too time consuming. Sometimes there are no good answers and sometimes there are but there is such a delay in diagnosis and treatment that it can become chronic as a result. The lack of collaboration is also a factor in complex situations. Some of this I think is a reflection of our broken system.

  • Ladyimacbeth

    I think it’s terrible that they would try and hold that physician responsible for the deaths of the patients when the patients were abusing the medications. That’s so wrong. Patients who abuse drugs can be quite creative and to blame the physician for that is just outrageous. It seems like physicians are damned if they do and damned if they don’t.

  • James O’Brien, M.D.

    Wait a second. Less than 5% of the world’s population consumes 80% of the world’s opioids, and this is described in the title as an “epidemic” of pain rather than of prescription drug use?

    I wasn’t aware that America was in the midst of a pain (which unlike Vicodin, never killed anyone) “epidemic”. If that’s true, how would you describe the pain felt by people in countries where, say breakbone fever is common?

    Epidemic? That’s a bridge too far as a descriptor. If you mean iatrogenic, then yes I agree.

    • T H

      “Pain is the 5th Vital Sign”

      Everything went downhill from there because JCAHO got everyone running scared… and the running all happened in one direction. Now, all we can do is close the door after the horses have fled the barn.

      Explaining hyperalgesia to a layperson is very, very difficult. I’ve tried dozens, possibly hundreds of times: the end of the conversation is usually “So, Doc, you gonna refill my Norco, or what?”

      • James O’Brien, M.D.

        Or what=or your Yelp and Press Ganey get hammered.

  • medicontheedge

    Where is the patient/customer in your discussion? THEY are the critical factor here. It would be interesting to see the breakdown of numbers of deaths by overdose by whether the patient was a drug abuser/seeker vs patients who responsibly manage their pain meds.

  • Peter Schwimer

    Perhaps its time for us to understand that we are imperfect beings in an imperfect world. Pain remedies are big business for drug companies and those who prescribe. Maybe we should get used to living. There are many folks who function quite well with non medicated pain. As there are many folks with pain symptoms who actually have untreated mental health issues which may in fact be a.bigger problem

  • Dr Jones

    Not many physicians realize that the Federation of State Medical Boards has quietly deleted the requirement that physicians treat pain from its Model Policy on opiate prescribing.

  • Kim Miller

    A refreshing article that centers on the REAL victims , chronic pain patients. People who never asked to be stricken with their particular diseases, people who, for the most part, have followed all the rules, gone through all the drug screenings, all pill counts, all th we extra appointments, but the cause of the problem is STILL there.

    No matter how much suffering the pain patients are made to endure, one constant remains, DRUG ADICTS STILL GET DRUGS.

    So the sacrificial lambs, the weakest, the sickest, they are still paying the price for what other people have done. All these patients want is to maintain some semblance of a quality of life in a painful,”War on Pain Patients”, that, at this has no end in site.

    SEE: Opposition for HB 1- Reform HB 217 aka “Pill Mill Bill”

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