FEAR AND LOATHING
IN THE PAIN CLINIC
Pain Medicine
Volume 7 Page 363 - July/August 2006
doi:10.1111/j.1526-4637.2006.00189.x
Volume 7 Issue 4
Fear and Loathing in the Pain Clinic
Steven D. Passik, PhD* and Kenneth L. Kirsh, PhD+
The piece by Jung and Reidenberg presents updated information on U.S. Drug
Enforcement Administration (DEA) activities against physicians that we have
heard reported on multiple occasions over years as pain professionals, both
attending and speaking at conferences. Often presented by active or retired
members of law enforcement, such data were nearly believable enough to be
taken at face value during the Hutchinson years at the DEA, when balance and
collaboration were the stated goals of the agency in its interactions with
pain professionals. "The DEA is not after you; the DEA does not want to tell
you how to practice medicine" was often the theme. Never mind the fact that
at every advisory board or meeting there was always at least one physician
in attendance who had been the subject of an investigation, their life,
reputation, and practice disrupted or ruined, pointing out the platitudes
inherent in such comments. Always there appeared to be an undertow of fear
related to the suggested disconnect between the preaching in Washington at
the top of the agency and what was "really happening in the field," where
agents and prosecutors often see things differently. In recent years,
reassurances related to data suggesting a miniscule number of
investigations, arrests, and sanctions ring hollow. These numbers seem
particularly tiny when the "denominator" utilized is the total number of
physician-registrants in the United States, all 936,385 of them. It makes
any fear of DEA action appear to be nothing more than a collective neurosis
shared by physicians who treat pain and/or prescribe controlled substances.
However, the presentation of these data begs the question: what is the
denominator? Also, why are so many physicians and organizations involved in
the treatment of pain worried when they have been specifically told that
they will not be sanctioned for prescribing opioids [1,2]? The denominator
is the key to a better understanding of the fear.
The only thing we have to fear is fear itself - nameless, unreasoning,
unjustified, terror which paralyzes needed efforts to convert retreat into
advance.
Franklin Delano Roosevelt
First Inaugural Address (1933)
Are pain physicians running scared? Are they afraid of their own shadows? Is
the fear of regulatory oversight in pain practice regarding the prescribing
of controlled substances a figment of their collective imaginations? If the
data presented by Jung and Reidenberg are an accurate representation of DEA
action against doctors, then it is time for a serious re-evaluation of our
field and its members. The numbers, as presented now and similarly in the
past, suggest that the likelihood of punitive action, arrest, and/or
conviction for issues related to opioid prescribing are as likely as winning
the lottery or being hit by lightning. But this is simply not the case.
Let's deal with the numerator. Tables 1 and 2 in the article present
"Arrests of Physicians" (N = 47) and "DEA Revocations" (N = 56) for the year
2003. Miniscule numbers, certainly; but are these numbers representative of
the true impact of the DEA on pain practice? We think not. Investigations of
a physician's practice are time-consuming, embarrassing, sullying of
reputations, costly, and distracting, to use just a few of the commonly
heard (and printable) adjectives. Even if vindicated in the end, the damage
is often done with regard to lost time, reputation, referrals, revenue, and
the physician's resolve (to treat pain aggressively, advocate for patients,
etc.) by the time the proceedings are completed.
One of us (S.D.P.) was once talking with Mary Baluss, a well-known attorney
who advocates for pain physicians and patients, and was bemoaning the fact
that physicians are so fearful in treating pain and advocating and
sacrificing for their patients. S.D.P. pointed out that this was from
members of a profession that historically had laid down their lives to care
for sick people with infectious diseases, only to succumb themselves at
times. Ms. Baluss pointed out, though, that sacrificing one's life is heroic
and final. Having one's (and one's family's) livelihood threatened; and
having to face living after one's good name and reputation have been dragged
in the mud; having been portrayed as a drug dealer and pariah in the
community is on some level harder and even more to ask of a physician. And
physicians are often perceived as guilty simply because they are being
investigated, which influences prescribing in their community. As Rebecca J.
Patchin, who serves on the board of the American Medical Association, told
the media,
"Doctors hear what's happening to other physicians, and that
makes them very reluctant to prescribe opioids that patients might well
need" [3]. Further, as Jung and Reidenberg point out, this does not even
take account of investigations stemming from local authorities and state
medical boards.
Therefore, we believe the most important "numerator" in the article is the
number of investigations begun in the first three quarters of 2003 (N =
557). Prorated out to 12 months, there would be approximately 742
investigations expected for the full year of 2003. Investigations of only
742 physicians in a year still suggests that a very small percentage (
0.07%) of physicians will be affected - if that number is juxtaposed against
the total number of physician registrants (N = 936,385). But is the total
number of physicians the true denominator? We tend to not think so, as it
does not reflect the reality of the government's impact on pain management,
as demonstrated below.
What if the denominator is the number of self-identified pain experts in the
United States? These physicians are probably the most likely to be targeted
because of the volume of their prescribing of controlled substances. It is
well known that a very small subset of physicians prescribe a
disproportionate percentage of opioids for pain. For example, 30,000
physicians in this country prescribe 85% of all of the modified release
opioids used for chronic pain. So only a handful of doctors (approximately
3%) are likely to practice state-of-the-art pain medicine and therefore make
sense as targets for investigations.
Ronald Libby, MD, writing for the Cato
Institute, used such an approach when he commented on the situation
surrounding data for 2001 [4]. He concluded that 17% of pain specialists
were investigated by the DEA in 2001 (when there were 861 investigations of
the roughly 5000 doctors considered pain experts). Applying such a formula
now, the numbers are very similar, with 742 investigations representing 15%
of the 5000 pain experts. Fifteen percent of physicians is a far cry from
less than a 1/10th of a percent of physicians when chilling effects and
negative impacts are being discussed.
One of the things which danger does to you after a time is, well, to kill
emotion. I don't think I shall ever feel anything again except fear. None of
us can hate anymore - or love.
Graham Greene
The Confidential Agent (1939)
Needless to say, fear is not good for patient care and empathy is commonly
an early victim [5,6]. As physicians respond to their fear by "identifying
with the aggressor" and taking on more and more of the law enforcement role
in their practice, concern for patients takes a back seat. Survival of the
practice and protection of oneself naturally become "job one." Doctors and
patients in pain become adversaries.
We must begin the process of reducing fear if pain management is to get back
on track. One approach would be to limit investigations of physicians.
Perhaps only when the medical board has concluded that something medically
inappropriate has occurred should the possibility of law enforcement
involvement be considered. Recent revelations about the magnitude of
nonphysician sources of opioid diversion [7] cast doubt on the legitimacy of
targeting physicians in the first place. It seems that law enforcement
investigations can and should be targeted elsewhere in the supply chain in
the search for criminal activity. Certainly, fewer than 10�15% of physicians
who aggressively treat pain deserve to be investigated. Until a new accord
is reached or some policy changes are effected, physicians who treat pain
will have more to fear than fear itself.
Steven D. Passik, PhD* and Kenneth L. Kirsh, PhD+
References
1 Federation of State Medical Boards of the United States, Inc. Model
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2 Hargus E, Trotta P, Gilson A, Russell DR, Dinnan MS. The Medical
Examining Board speaks on pain management: Everyone should listen. Conn Med
2005; 69:485�91.
3 Haines ML. Federal crackdown on pain specialists doesn't help
patients. Asbury Park Press, December 15, 2005.
4 Libby RT. Treating doctors as drug dealers: The DEA's war on
prescription painkillers. Policy Analysis Monograph no. 545. The CATO
Institute, Washington, DC. Published June 6, 2005.
5 Irving P, Dickson D. Empathy: Towards a conceptual framework for
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6 Jotkowitz AB, Clarfield M. The physician as comforter. Eur J Intern
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7 Joranson DE, Gilson AM. Drug crime is a source of abused pain
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