Damned if you do, damned if you don’t (or how to get caught between a rock and a hard place)

Worried Pain Doctors Decry Prosecutions

In recent years, similar charges of illegally prescribing prescription narcotics, criminal conspiracy, racketeering and even murder have been brought in dozens of states against scores of doctors who treat chronic pain with prescription narcotics. At least two have been imprisoned, one committed suicide, several are awaiting sentencing, many are preparing for trial, and more have lost their licenses to practice medicine and accumulated huge legal bills.

Top DEA officials say only a relative handful of doctors have gotten into trouble with the law and that all were prescribing drugs outside medical norms in a manner that amounted to trafficking. The prosecutions, they say, have had a positive effect.

“There have been a number of very high-profile cases, and they have been a learning lesson to other physicians,” said Elizabeth Willis, chief of drug operations for the DEA Office of Diversion Control. “We think doctors are much more aware of appropriate guidelines for prescribing OxyContin now.”

But increasingly worried pain specialists say that although some doctors may be running narcotic “pill mills” and even selling prescriptions for narcotics, many others who have been arrested appear to be responsible physicians.

Their crime, it seems, is that they were supplying their chronic pain patients with sometimes large numbers of prescriptions for controlled but legal medications to treat their pain. The result, the doctors say, is that the established medical use of opium-based drugs for pain is becoming criminalized by aggressive drug agents and zealous prosecutors.

On the one hand we (physicians) are urged to attend to pain. To not address a patient’s pain issue leaves us open to intense criticism. This guideline addresses the issue – MODEL GUIDELINES FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN

Inadequate pain control may result from physicians’ lack of knowledge about pain management or an inadequate understanding of addiction. Fears of investigation or sanction by federal, state, and local regulatory agencies may also result in inappropriate or inadequate treatment of chronic pain patients. Accordingly, these guidelines have been developed to clarify the Board’s position on pain control, specifically as related to the use of controlled substances, to alleviate physician uncertainty and to encourage better pain management.

The Board recognizes that controlled substances, including opioid analgesics, may be essential in the treatment of acute pain due to trauma or surgery and chronic pain, whether due to cancer or non-cancer origins. Physicians are referred to the U.S. Agency for Health Care and Research Clinical Practice Guidelines for a sound approach to the management of acute1 and cancer-related pain.

The medical management of pain should be based upon current knowledge and research and includes the use of both pharmacologic and non-pharmacologic modalities. Pain should be assessed and treated promptly and the quantity and frequency of doses should be adjusted according to the intensity and duration of the pain. Physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.

We have adopted pain as the 5th vital sign. This VA document discusses the importance of attending to pain – Pain as the 5th Vital Sign: Take 5.

Pain control challenges us daily. We have no great objective quantification of pain. Patients can fool us. Thus we are damned if we ignore and damned if we treat too aggressively.

This story is scary. We need a better method for controlling physicians who overprescribe pain medications. DEA arrests are not the answer. Back to our article –

“Fifteen years of progress in treating patients in chronic pain could really be wiped away if these prosecutions continue,” said Russell K. Portenoy, a pain specialist at Beth Israel Medical Center in New York who is considered one of the fathers of modern pain management. Since the mid-1980s, Portenoy has been advocating the use of morphine-based drugs to address what he considers to be the widespread, unnecessary and even cruel undertreatment of chronic pain.

“Treating people in pain isn’t easy, and there aren’t black-and-white answers,” he said, agreeing that some doctors have not been sufficiently careful about potential problems with addiction and diversion of drugs. “But what’s happening now is that the medical ambiguity is being turned into allegations of criminal behavior. We have to draw a line in the sand here, or else the treatment will be lost, and millions of patients will suffer.”

Amen!