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Dr. Howard Heit does an
excellent and accurate job in his piece
Professionals and the DEA: Trying to Get Back in Balance; Heit; 2006], expressing the hope and disappointment
many of us felt in advance of and following our opportunity to speak with the
Drug Enforcement Administration (DEA) about the interim policy statement (IPS).
I was also "in attendance" that day, but due to other commitments participated
via telephone. I listened intently until it was my turn. Those who went before
me described the negative effects of both aspects of the IPS and the pulling of
Prescription Pain Medications: Frequently Asked Questions and Answers (FAQ) (of
which I was one of the authors). It was hard to judge the mood in the room. The
DEA representatives were in listening mode, so without seeing them, I could not
easily tell how the reasoned arguments and statements being made (not just by
those who prescribe controlled substances, but also by those who have seen the
negative impact of the IPS on pharmacy and nursing practice) were being
received. I was hoping for the best.
The FAQ was meant not as a policy statement but as a document to help DEA agents
better understand the way pain medicine is practiced. It was a guide to foster a
better understanding of the realities of pain medication prescribing—its
complexities and some of its subtleties—to help begin to break down the myths
that surround some of the simple-minded formulas like number of pills, number of
prescriptions, and number of opioids to the same patient, and myths about
addiction that have been historically and mistakenly applied in an effort to
find the doctor-turned-drug-dealer. The FAQ document was meant to help agents
get a sense of the phenomenology of the well-intentioned physician who struggles
to treat pain and not contribute to drug abuse and diversion. How confusing the
assessment of addiction and diversion can be when you are trying to treat pain.
I remember expressing my doubts and cynicism on the very first conference call
between the group of us who were to write the FAQ. I remember saying that even
at a time of greater cooperation between the DEA and the pain community, I
perceived a disconnect between the statements coming from the top and the actual
practices on the ground. I remember that some from the DEA on that call were
(mildly?) offended at my comments; this was after all to be a new era. Greater
balance, greater cooperation. And I was urged to press on and contribute in the
name of education and the spirit of cooperation. The group worked hard on
multiple drafts. No "misstatements" were made regarding the confusing realities
of life as pain practitioner and its peculiar phenomenology.
It is my concern that misstatements are routinely being made, though, about pain
practice in everything from high-profile court cases to the IPS. Proposing
ceiling effects to opioid doses and obscuring the legality of prescribing to
those with a history of drug abuse are two. But perhaps the one most offensive
to me is the distortion of aspects of my work on potentially aberrant
drug-related behavior. This model of clinical assessment and research has
revealed that noncompliant behavior is common among those on opioids and stems
from many different etiologies, from addiction and diversion to untreated pain
and psychological distress, to name a few. My studies have found such behaviors
in 45% of opioid-treated, chronic pain patients , and Lynn Webster has found
the same . Thus, these behaviors are common. Much more research is needed to
better understand them and to calculate the probabilities that they are related
to one cause or other or how many behaviors over time are related to addiction.
These behaviors are not to be ignored—but they are NOT "red flags"—red flags
implies that prescribing should be discontinued at the emergence of the
behavior. They are "yellow flags" at best. Proceed with caution. Apply
limit-setting, change management. Be thoughtful. Use your leverage as a
physician to help the patient be compliant; maybe use the fact that they need
pain management as an impetus to seek drug abuse treatment, too. In other words,
react therapeutically, not punitively. I started this work to help physicians
better understand addiction so as to increase their comfort level in prescribing
and assessing their patients.
When the spirit of cooperation between the DEA and the pain community breaks
down, there is little therapeutic "wiggle room" in these situations. Physicians
begin to assume aspects of the law enforcement role into their practices, and
"one strike and your out" policies begin to appear in pain clinics. Flunk a
urine, kicked to the curb. Run out early, ditto. Complain too aggressively,
ditto. Where might it end; the unjust discharge of half of patients on opioids?
No pain treatment? The DEA says that they do not want to tell you how to
practice medicine. But they don't have to—directly. I am afraid that this is the
upshot of the pulling of the FAQ and aspects of the IPS.
I have in the past and will continue in the future to advocate for physicians in
legal and other (i.e., medical board) arenas. I am particularly motivated to set
the record straight when the distortion of the realities of pain management is
being used against them. And I will continue to do this work. The reason is
simple: Without a proper understanding of these issues, patients suffer. When I
left the Markey Cancer Center at the University of Kentucky, the Symptom
Management and Palliative Care program unfortunately closed its doors. We tried
for months to get all of our patients to practitioners who would prescribe their
opioids. Some of these patients were complicated, no doubt. Equally clear is the
fact that central and south-eastern Kentucky are areas hard hit by prescription
drug abuse and diversion. It was difficult and in some cases close to
impossible—and these were people with cancer.
1. Passik SD, Kirsh KL, Whitcomb L, et al. Monitoring outcomes during long-term
opioid therapy for noncancer pain: Results with the pain assessment and
documentation tool. J Opioid Manage November/December 2005;1(5):257–66.
2. Webster LR. Predicting aberrant behaviors in opioid-treated patients.
Preliminary validation of the opioid risk tool. Pain Med 2005;6(6):432–42.
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