This tragic—yet intriguing—topic has captured non-stop media attention for the past 10 years. Sadly, the same tragedy befalls everyday people but their stories aren’t sensational enough to make the news.
When I met Arianna Huffington on an airplane last weekend, she insisted that I share my insight with the Huffington Post about this topical issue I am so passionate about.
As a skilled and experienced Pain Management physician, I frequently see people with narcotic addictions that masquerade as physical pain. In fact, it is physical pain because withdrawal from narcotic medications and illicit substances causes an extremely painful cascade of physical phenomenon. More often than we doctors realize, patients end up in the emergency room with symptoms of nausea, vomiting, abdominal pain and chills because they are in the throes of acute narcotic withdrawal. They are not suffering from an unidentified gastrointestinal infection or abnormality.
In the E.R., they undergo a lengthy and expensive evaluation, often without insurance coverage, that doesn’t reveal any abnormal physical process. They are given intravenous Dilaudid for the abdominal pain and, should the symptoms return, a prescription for Vicodin to go home. In actuality, they’ve just been given the treatment for narcotic withdrawal and a nice little supply of more “medicine” to feed the addiction.
The often heard question during the Anna Nicole Smith trial is ”Was she addicted to pain killers or not?”. It really doesn’t matter whether she was being treated for chronic pain or being given narcotics to quell an addiction. She’s dead now and there are no more opportunities to help her. The question should be, “Why were those two doctors, a psychiatrist and a geriatric/internal medicine specialist, prescribing large quantities of highly potent narcotics to Anna Nicole Smith?”.
Unfortunately, both of Anna’s doctors were treating her outside of the limits of their medical expertise. It’s now an all too common phenomenon for physicians to treat problems that are outside of their primary field of training and board certified qualifications. The major risks taken in assuming the role of a pain management physician are:
- Poor patient selection for treatment with narcotics
- Worsening addiction
- Diversion of narcotics to the street or at risk friends and family members
- Overdose and death
Why would any physician want to take on that task and risk without proper insight and training? The worst possible outcome isn’t a botched boob job—it’s death.
Prescription medicine is now the highest abused substance in the United States. We doctors are primarily to blame for this. We’re prescribing the drugs to patients at much higher rates than before.
Most physicians don’t have adequate training or knowledge of these controlled substances and the patient population that regularly requests them. In California, a Pain Management initiative went into effect in 2003 due to the law case of Chin v. Eden Hospital. A 1.5M dollar settlement was paid out to the family of a patient for Elder Abuse from inadequate pain management. Since then physicians from every specialty have been encouraged—even feel pressured—to treat all patients’ pain complaints. The California Medical Board mandated completion of 13 hours of continuing education credits in pain management to renew all physicians’ state medical licenses. 13 hours of pain management continuing education is enough information to know when to refer a patient to a pain management specialist. It’s certainly not enough training to act as a pain management specialist.
Pain Management is a one year fellowship training program after a four-year anesthesiology residency. Anesthesiologists have in-depth knowledge of pharmacology, physiology, pharmacokinetics, pharmacodynamics and drug-drug interactions. This information allows us to safely anesthetize patients for surgery with minimal pain. No other residency devotes as much time to understanding how drugs work in the body and how drugs interact with other medications during the painful perioperative period.
Pain Management specialists then transfer that knowledge to an outpatient setting to treat chronic pain. During the extra year of training, we develop an acute understanding of how a person’s psychological state affects pain perception and treatment; how to effectively use controlled substances and non-controlled substances to treat pain with as little risk possible; how to identify patients who are not good candidates for controlled substances and ,maybe most importantly, how to say “NO” to prescribing more controlled substances to patients who are not benefitting from them or who show signs of addiction or other adverse side effects.
Dr. Perry Fine testified in the Anna Nicole Smith case that her use of 1,500 pills per month of controlled substances was not a definition for addiction. He’s right—it’s not enough evidence to prove she was addicted. To diagnose addiction, a constellation of psychosocial behaviors and physical symptoms need to be identified and documented. Some of the factors that we use to diagnose addiction are:
- Excessive use of medication
- Obtaining controlled substances from more than one physician
- Continued use despite harm of a controlled substance.
Anna Nicole exhibited all of those “red flags”. The question that should have been asked of Dr. Fine is “Would 1,500 pills per month be a reasonable amount of medication given Anna Nicole’s documented pain diagnosis, response to treatment and functional level on the medications?”.
Without hesitation, the answer is, “Absolutely not“.
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The Medical Advocate
This tragic—yet intriguing—topic has captured non-stop media attention for the past 10 years. Sadly, the same tragedy befalls everyday people but their stories aren’t sensational enough to make the news.
When I met Arianna Huffington on an airplane last weekend, she insisted that I share my insight with the Huffington Post about this topical issue I am so passionate about.
As a skilled and experienced Pain Management physician, I frequently see people with narcotic addictions that masquerade as physical pain. In fact, it is physical pain because withdrawal from narcotic medications and illicit substances causes an extremely painful cascade of physical phenomenon. More often than we doctors realize, patients end up in the emergency room with symptoms of nausea, vomiting, abdominal pain and chills because they are in the throes of acute narcotic withdrawal. They are not suffering from an unidentified gastrointestinal infection or abnormality.
In the E.R., they undergo a lengthy and expensive evaluation, often without insurance coverage, that doesn’t reveal any abnormal physical process. They are given intravenous Dilaudid for the abdominal pain and, should the symptoms return, a prescription for Vicodin to go home. In actuality, they’ve just been given the treatment for narcotic withdrawal and a nice little supply of more “medicine” to feed the addiction.
The often heard question during the Anna Nicole Smith trial is ”Was she addicted to pain killers or not?”. It really doesn’t matter whether she was being treated for chronic pain or being given narcotics to quell an addiction. She’s dead now and there are no more opportunities to help her. The question should be, “Why were those two doctors, a psychiatrist and a geriatric/internal medicine specialist, prescribing large quantities of highly potent narcotics to Anna Nicole Smith?”.
Unfortunately, both of Anna’s doctors were treating her outside of the limits of their medical expertise. It’s now an all too common phenomenon for physicians to treat problems that are outside of their primary field of training and board certified qualifications. The major risks taken in assuming the role of a pain management physician are:
Why would any physician want to take on that task and risk without proper insight and training? The worst possible outcome isn’t a botched boob job—it’s death.
Prescription medicine is now the highest abused substance in the United States. We doctors are primarily to blame for this. We’re prescribing the drugs to patients at much higher rates than before.
Most physicians don’t have adequate training or knowledge of these controlled substances and the patient population that regularly requests them. In California, a Pain Management initiative went into effect in 2003 due to the law case of Chin v. Eden Hospital. A 1.5M dollar settlement was paid out to the family of a patient for Elder Abuse from inadequate pain management. Since then physicians from every specialty have been encouraged—even feel pressured—to treat all patients’ pain complaints. The California Medical Board mandated completion of 13 hours of continuing education credits in pain management to renew all physicians’ state medical licenses. 13 hours of pain management continuing education is enough information to know when to refer a patient to a pain management specialist. It’s certainly not enough training to act as a pain management specialist.
Pain Management is a one year fellowship training program after a four-year anesthesiology residency. Anesthesiologists have in-depth knowledge of pharmacology, physiology, pharmacokinetics, pharmacodynamics and drug-drug interactions. This information allows us to safely anesthetize patients for surgery with minimal pain. No other residency devotes as much time to understanding how drugs work in the body and how drugs interact with other medications during the painful perioperative period.
Pain Management specialists then transfer that knowledge to an outpatient setting to treat chronic pain. During the extra year of training, we develop an acute understanding of how a person’s psychological state affects pain perception and treatment; how to effectively use controlled substances and non-controlled substances to treat pain with as little risk possible; how to identify patients who are not good candidates for controlled substances and
Dr. Perry Fine testified in the Anna Nicole Smith case that her use of 1,500 pills per month of controlled substances was not a definition for addiction. He’s right—it’s not enough evidence to prove she was addicted. To diagnose addiction, a constellation of psychosocial behaviors and physical symptoms need to be identified and documented. Some of the factors that we use to diagnose addiction are:
Anna Nicole exhibited all of those “red flags”. The question that should have been asked of Dr. Fine is “Would 1,500 pills per month be a reasonable amount of medication given Anna Nicole’s documented pain diagnosis, response to treatment and functional level on the medications?”.
Without hesitation, the answer is, “Absolutely not“.
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