Why Treat Chronic Non-Malignant Pain with Pain Medication? (Duh!)
Saturday, June 15, 2013
Posted by: Joy Ingram
Confessions of an Opioid Prescriber
By Harry H. Rinehart, MD, ABFP, CAQ Geriatrics, FAAFP; Medical Director, The Rinehart Clinic, Wheeler, OR
**Editor's Note: NWRPCA seeks to provide a forum for discussion by all competent participants with a reasonable point of view expressed respectfully and professionally and in good faith. We do not profess to have a "position" or "correct answers" about clinical and care issues. We are serving here as conveners and facilitators, inviting all reasonable perspectives and willing to present evidence from all responsible sources.**
[Editor’s additional note: We asked this innovative, outspoken 68-years-young CHC physician to tell the story of his 32-year journey to find peace with pain treatment and opioid prescribing. One of our most sought-after preceptors, he has pulled no punches. His story is bold and courageous, touching and taunting. We recommend you read it all the way to the surprise ending – an ending that surprised us too.]
It’s 1982. I’m 36 years old and in my first rural family practice in Prineville OR, over $400,000 in debt, when the Oregon Board of Medical Examiners (BME) sends an investigator to town. After three days doing a clandestine investigation of my prescribing practices, he finally finds what he’s been looking for: I have prescribed # 4 - 5/325 Percocet a day to one Grace Keilholtz, 86 years old and residing in the local nursing home. Grace has osteoarthritis of her knees. Without treatment, it keeps her in a wheelchair and awake at night.
The investigation scared the bejeezus out of me and, cowardly, I tapered her off. Grace, whom I dearly loved, died in pain. I’ve never forgiven myself, never will. This experience set me on a quest to discover just what the Board was concerned about, a quest to discover what would be “appropriate prescribing” for chronic pain. Nothing in medical school, residency, or my life experience growing up in a rural community with two physicians for parents had prepared me to deal with such a concern. Apparently naïve, I thought pain medication was to treat pain.
“It can’t be done!”
I began going to “Pain Treatment” conferences. I learned there was no way for a rural practitioner to treat chronic pain at all, as it could be done only in a “Multi-disciplinary Pain Clinic.” These platitudes were expressed by - you guessed it - physicians who owned such facilities, and professors who could garner the requisite staff under their roof for patients who could afford them. (This leaves about 75% of patients with chronic pain no place to go.) Furthermore, it was considered suspect to treat any pain without “objective evidence.” What do I do for my Fibromyalgia patients, my headache patients, and my patients with CRPS, I wondered. All the while I was treating these patients with opioids and seeing most benefit, hoping to stay under the Board’s radar.
When I opened up my BME quarterly report one day in the late ’80’s I found a major article identifying just who these doctors were who were prescribing inappropriately. Have you ever been “profiled”? There I was, the middle-aged, male, rural physician. This white boy suddenly experienced real empathy for every African American, every Mexican American, every minority who has ever been pulled over for the color of their skin or other such infraction. It was a very humbling experience - which most of us have coming.
I’m a fourth-generation Oregon rural physician. My great grandmother, Belle Cooper Rinehart, graduated from the University of Oregon Medical School in 1897. She was followed by my grandfather, H.E. Rinehart in 1907, and by my parents, R.E. and Dorothy White Rinehart, in 1941. My lineage cut no hair. Suddenly I was a member of a targeted minority. My wake-up call. It appeared my vernacular was now spoken by a dwindling population targeted for extinction.
I had to slink down in my chair
Off to Opioid Addiction Conferences I went, hoping to learn what had apparently been going over my head, as I continued to treat my rural patients, most of whom continued to do well, to work, raise their children, exercise, lose weight, and get over being depressed as they could now sleep. At these conferences I really had to slink down in my chair. Here I learned I was nothing more than an “enabler,” with a craven need for my patients to be dependent on me, which I cultivated by “supplying” them with addicting drugs. And, furthermore, these were not medications but “Drugs of the Devil!” One sad day I had the audacity to ask one of the presenters to clarify why the patient he was describing was inappropriate for treatment. He exploded, giving me a sneering tongue-lashing for my inability to understand that which to him was obvious. Here I learned, “Do not ask questions of a zealot.” I wasn’t much further along in my quest to figure out how to prescribe opioids responsibly. Apparently unable to assess risk, I continued to treat my patients.
Then in 1995 The Oregon Pain Act was passed. The Act prohibited the BME from rescinding a doctor’s license to practice medicine solely for prescribing opioids for chronic non-malignant pain. What? Did I hear that right? Was it okay to treat pain if a person were going to die, but not if they were going to live? Was it really necessary for Oregonians to pass a law to allow doctors to treat chronic non-malignant pain? You bet it was! Many physician suicides preceded the passage of this law, good physicians who had been stripped of their calling due to prior Board policy.
Many of us breathed a sigh of relief. “Not so fast,” the Board replied in its next quarterly newsletter. “Nothing’s changed. The Board has always advocated for the reasonable treatment of pain.”
Then, with good intentions, we overprescribed
Things had changed. We entered the era of prescribing pain meds with the knowledge available at the time, inadequately educated and unable to detect for whom they would be a problem, (not that we have any crystal balls now). We were unaware that many of these medications would make their way into the hands of those who would abuse them, become addicted to them, or engage in criminal activity because they had access to them. Hubris? It certainly preceded the fall.
Time marches on. In 2006, at the age of 61, I was way too old for this level of stress when my own county DA reported me to the BME for supplying opioids to a total of 9 patients over two years who, he alleged, didn’t need them, were selling them, had committed suicide on them. This cost me several nights’ sleep. Malpractice insurance doesn’t defend you for criminal activity. They can take your license, your home and your retirement.
Now I want to say the BME did a very thorough and fair analysis. They listened to my side of the story as well as the DA’s. They reviewed our comprehensive Pain Management Policy and Procedure, and hundreds of hours later I emerged vindicated, scarred by the experience, but committed to continue to treat my patients without discriminating based on diagnosis.
Why is it we cannot legally discriminate based on color, creed, gender identification and nearly a dozen other attributes of an individual, yet we are allowed, as physicians, to discriminate based on diagnosis? This truly puzzles me. Not all patients with chronic pain are our enemies. In fact, most are great people, and every single one of them is a person we have taken an oath to serve to the best of our ability. How did the patient with chronic pain become so demonized? Could it be a few rotten apples have been spoiling the entire barrel?
We knuckled down. Urine Drug Screens, pill counts, Opioid Risk Scores, Treatment Agreements, Informed Consents three pages long, Zung depression screens and sleep apnea screens at every visit, lock boxes and pain groups. What a production caring for patients with chronic pain has become! The stigma becomes increasingly difficult for patients to endure.
But, while some find pain relief, others die
Meanwhile, the deaths attributable to opioids continue to pile up. By 2010 as many persons died from medication overdoses as died on our nation’s highways. How many of these medication overdoses were opioid overdoses? About 2/3, or 16,500. In the same year, 16,500 died from taking ibuprofen, naproxen, aspirin, all OTC and prescribed NSAIDS. 107,000 persons were admitted to hospitals for NSAID-related side effects. Where, many of us wondered, were the headlines screaming of this problem? Not that it matters. Putting things in perspective doesn’t sell papers.
And how many of the deaths attributable to opioids were solely due to opioids? Not nearly all, but if you never want to see your patient again, give him or her a methadone-Soma-Xanax cocktail, don’t screen for prolonged QT interval, and don’t do an Apnea-Link. That’s the lethal cocktail, with the QT/Central sleep Apnea chaser. (“Say goodnight, Gracie.”)
The opio-phobes were beginning to get to me. I was privileged to join the Oregon Pain Commission and worked hard for several years to establish the Oregon Prescription Drug Monitoring Program. Who opposed this legislation initially, and why did it fail in the legislature the first time up for a vote? Well, of course the ACLU. That’s their job. But the main reason it failed was that our colleagues in the Oregon Medical Association opposed it. Why? Because it was going to cost their poor doctors a whopping $25.00 apiece! I’ve never been so ashamed of my profession. Two years later it passed and, as you now know, it is one of the best tools at our disposal to prevent the doctor-shopping we knew was going on but couldn’t detect. But no one relaxed.
Finally, some comrades!
I began the 200-mile round-trip monthly trek after work to attend the Oregon Pain Society meetings in Portland. This is a multi-disciplinary group, all members of which work hard to address the treatment of chronic pain. Finally, some comrades! Not looking to find fault, rather looking to find what would provide a measure of relief. Wow! What I learned! Microcurrent, music therapy and Glial Cells. Acupuncture, chiropractic and hypnosis! The pain treatment soup was deep and wide. Our Psych NP, Milar Moore (Yes, we’re integrated, with mental and behavioral health as part of primary care in our clinic) and I attended a hypnosis training at OHSU. My wife Nancy and I attended extensive Frequency Specific Microcurrent seminars. We started providing microcurrent treatment in our clinic.
Want to see someone get over diabetic neuropathy? Give them five microcurrent treatments as I did for R.D. This fellow’s diabetic neuropathy was so severe he could not go into Fred Meyer’s for more than ten minutes. Walking on the concrete floors was just too painful. Five treatments later, he was cured. Three years later, with no addfitional treatments, he remains cured. No pain. We have no medications that can approach the curative powers of microcurrent. We don’t understand exactly how it works, but it does work in 56% of patients. We know it increases ATP. We know it reduces inflammatory cytokines. We know the patient must be hydrated, or it won’t work. There are no “evidenced based” studies supporting that it does work, but work it does. And it is harmless.
In 2008 I felt obligated to address this problem of “opioid addiction” that, according to the opio-phobes, is due to physicians like me prescribing opioids for pain. So I go to Seattle and spend a G-note getting the coveted “X” certificate so I can prescribe Suboxone and begin treating the dreaded “drug addicts” I’m alleged to have created. I return to my rural roots and discover, to my dismay, the “drug addicts” are piling up at my door because they don’t want to be drug addicts. That’s not what I was taught at medical school and far beyond. I was taught the drug addict enjoyed being a drug addict, that they were “in love with the way they feel when on their drug.” (I have yet to treat a “drug addict” for whom I was the physician who got them hooked.)
I’ve never met a drug addict who didn’t want to quit
I soon learned this was a lot of nonsense. I have yet to meet a drug addict who didn’t want to quit. What hogwash we are exposed to! Think about it: If you were a drug addict, wouldn’t you want to quit? Wouldn’t you wish this monkey were off your back, that you could take care of your children, stop rotating in and out of prison, hold down a job, contribute to society instead of being a leech? Of course you would, and so do they. We’re all pretty much of the same ilk, unless we’re pathological psychopaths. Our children afflicted with drug addiction are just that...our children. Let’s get real.
Now I’ve got 100 patients afflicted with opioid addiction at any one time because that is all the law allows - or I would have 120. The waiting list is usually 20 patients long. And why is there a waiting list at all? The answer is because only one other physician on the north Oregon Coast has the “X” certificate. There are three CHCs on the North Coast. If each of them supplied one physician to treat addiction, there would be no waiting list, and soon there would be a lot less drug addiction and a lot less crime, and the CHCs would be supplying a very necessary community service.
I visited SAMHSA, the Substance Abuse and Mental Health Services Agency, headquartered in Rock Creek, Maryland, in December of 2011. They were puzzled as to why CHCs were not stepping up to the plate to treat drug addiction in their communities. It’s a nation-wide phenomenon. I got a clue recently when a physician I met, who had held the “X” certificate for three years, had not yet seen a single drug addict. He explained, “We don’t want to become known as ‘The Addiction Clinic.’” Now, I didn’t know how to reply to that, so for once I politely kept my mouth shut.
Addicts are all liars, right?
Let’s digress and talk about “liars” for a minute. All drug addicts are liars, right? Right. Do you know that after five years of weekly psychotherapy, patients have not always disclosed their deepest secrets to their psychiatrist? Do you tell everything about yourself to your doctor? Everything about yourself you are ashamed of? If you do, perhaps you need to see a therapist. Why is it we doctors think somehow we are above being lied to? Why is it, when we discover we have been lied to, we go berserk? Are we so special? Hubris. Look out for it.
I’ve got a daughter who is an adult serial-killer profiler with the FBI. I asked her one day, “Julie, how do you tell if a person is lying?” She looked at me with that “Are you serious?” look, composed herself, and as politely as she could, explained to me that neither I, nor she, nor anyone else (not even the lie detector), is able to tell if someone is lying or telling the truth. Furthermore, why would you want to? It doesn’t really matter what your prejudices are; it’s the facts we are after. I’ve learned to neither mistrust, nortrust, patients’ stories. Like Julie, I write them down and, over time, check them out. We’re all liars to some extent. It’s a social prerequisite. Persons caught up in the roller-coaster of drug addiction can tell some whoppers, but it is not about you, it’s about their desperation to avoid another withdrawal. They don’t like telling lies anymore than we like listening to them. Once clean, they are so ashamed of themselves!
I can understand, if I put myself back in my 2004 shoes, how doctors find it difficult to think anything but trash about “drug addicts.” So I and one of the great students from the Pacific University Physician Assistant Program, Thomas Haslam, and that great actor Megan Cole, made a video. It’s just ten minutes long, and I’d like you to watch it. If you don’t cry when you see that little girl in the coffee shop clapping her hands after getting a kiss from her “drug addict” mother, now clean for three years on Suboxone, please call me, and then call Rachel Naomi Remen and sign up for one of her courses on “Meaning in Medicine.” You’re burned out.
If you don’t find yourself grinning from ear to ear when you see that dad leaning back in his chair, himself grinning from ear to ear about how happy he is that his son is off drugs, call me, and call Rachel. You’re burned out. You’ll learn to ask yourself the three questions as you look at your patient schedule at the end of the day: What surprised me today? What inspired me today? What touched my heart? It’s why we went into medicine.
I was suspicious about NWRPCA’s pain management efforts
As a member of the Oregon Pain Commission, it is my job to see that Oregonians in pain do not have undue difficulty getting treated for painful conditions. Now that’ a tall order, and nearly impossible with the media touting the dangers of opioids. So I was suspicious when NWRPCA scheduled a full day at the Spring Conference in Anchorage this past May dealing with reducing the use of opioids for the treatment of chronic non-malignant pain. Thought I had better go, keep one foot in the camp of the enemy, so to speak.
How glad I am I went, and how pleasantly surprised I was! Here I learned how to stratify my pain patients into those Fully Engaged in their treatment, those Partially Engaged, who might move to full engagement with coaching, and thoseDisengaged, whom I was actually treating mainly for their suffering, not for their pain. Here I learned of resources, such as the University of Washington Wednesday noon Tele-Health connection where I could present my difficult cases to my peers. Here I learned of several tools which have been simplified for use in busy primary care clinics to assist with risk stratification, depression detection, and Engagement Classification.
I came back from that conference transformed from skeptic to enthusiastic supporter, eager to employ these new concepts and tools in my practice. Back in the clinic three weeks, I have already shared some of this knowledge with over sixty of my patients. (I developed a 14-page Patient Education handout, which I will get posted on our Web site.) When I define the three levels of engagement to my patients, they immediately get it. In fact, they are able to place themselves in the exact slot in which I see them! We agree, even if the slot is “Disengaged”!
You don’t have to fire your patients
These concepts are going to revolutionize pain management in our clinics. My patients have been able to see the necessity and advantages of moving along this continuum to full engagement and reduction for many to a Morphine Equivalent Dosage of 120 mg per day.
And here’s a pitch for seeing your pain patients in GROUPS: You simply can’t do this level of education in an individual appointment. It is too time-consuming. More importantly, these are Herculean concepts and hurdles for many; you need the power of the Group to bring about change in those who are Partially Engaged and Disengaged. It’s pretty easy for them to argue with me, but when they see their peers all getting on the bandwagon, it is very difficult for them to opt out.
I’ll be 68 this summer. It’s been a great ride to date and getting smoother every day. I’ll be treating patients with chronic non-malignant pain for at least another 15-20 years, The Board willing. You see, I think I’ve just about got it figured out.
If you’re not treating “pain patients” and “drug addicts,” you’re missing out on providing services to some of the greatest people you will ever meet in medicine. I encourage you to first get your Suboxone “X” certificate. [NWRPCA will be providing a Suboxone certification course at its Fall Primary Care Conference in Seattle October 19-22.]
Then, when it becomes clear you misdiagnosed a patient as having chronic pain, when actually they were suffering from the mental illness of substance abuse, you don’t have to blame them, but instead be able to calmly advise them: “It has become clear (it always does) that you are not suitable for treatment with standard opioids, but I have an alternative, more suitable program for you, and that is my Suboxone program.” You don’t have to “fire” them or send them elsewhere. This removes a great deal of the stress we all anticipate should we find out the patient is a “drug addict.”
Now, in 2013, all the tools are available to treat patients with chronic non-malignant pain and opioid addiction. Don’t forget, many patients have both. The knowledge is readily available about how to do this responsibly and effectively. Keep in mind why we were called to this great profession: to give our patients a leg up as they progress along life’s journey, and a caring hand to lower them gently down as they complete it. Remember, there but for the grace of God go you and I.
Oh, and always wear your cape.
Click here to watch The Rinehart Clinic Suboxone Program video.
[Editor’s note: Please join Dr. Rinehart and his staff in celebrating the 100th anniversary this year of The Rinehart Clinic of Wheeler, Oregon. NWRPCA welcomes responses to this and all articles appearing on our web site and in QuickNotes. In addition, NWRPCA seeks other Region X CHC providers who wish to join the dialogue about pain management and the risks of opioid prescribing – and good alternatives. Respond to membership@NWRPCA.org]
NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.