In Search of Relief: Pain Sufferers Caught in Medical Controversy
Billings Gazette; Issued: 2005-06-11; Posted: 2005-06-11; Modified:
EFFECT - the
withdrawal, for fear of litigation, by physicians from the appropriate
treatment of pain.
Cole Kimber pointed a revolver at his head and pulled the trigger. Click.
He pulled again. Click.
He wanted to be ready.
"You've got to prepare yourself psychologically for it," Kimber said. "Suicide might be an option."
It wasn't the only way the Billings man rehearsed killing himself. He also closed the garage door and started his car. He wanted to know how much time would pass before he could no longer smell the exhaust.
Without medication to muffle red-hot pain radiating from his back, injured almost 20 years ago moving furniture, "My quality of life isn't worth it," Kimber said.
He nearly reached his breaking point a few weeks ago when his prescription for an opioid, or narcotic painkiller, ran out. His doctor, Richard A. Nelson, cannot renew the prescription because the federal Drug Enforcement Administration suspended his privileges to dispense certain drugs.
DEA agents raided the Billings neurologist's office in April. No charges have been filed against Nelson - who is not to be confused with retired Billings internist Richard C. Nelson - but an investigation is ongoing, said Karen Flowers, a DEA spokeswoman in Denver.
Flowers would not say what federal agents are investigating. Nelson's attorney, Bob Fain, said the investigation was focused on "regulatory issues" but that he did not have details.
Nelson's medical license has not been affected, and he continues to see patients at his West End office. But dozens of his clients have had to turn elsewhere to renew prescriptions.
In doing so, many have run headlong into a controversy over the use of narcotics to treat chronic pain.
On one side are people like Kimber, who say they cannot function day to day without medication to stifle their pain, and a growing number of physicians who believe them. Still more doctors and much of the public come down on the other side, arguing that people in pain should "cowboy up" or learn to live with it. Those who seek narcotics for pain, some say, are just drug addicts, and doctors who prescribe the controlled substances are enablers or - worse - dealers.
Treating chronic pain with opioids - the medical term for narcotic painkillers - is a relatively new practice that is still broadly misunderstood, said Jeannine Brant, a nurse at St. Vincent Healthcare who specializes in pain management.
Two decades ago, physicians did not prescribe opioids for patients suffering from chronic pain. But Brant said studies have gradually disproved fears about narcotics as maintenance drugs: Most patients do not grow tolerant of the powerful painkillers. Most do not become addicted. Most can function with a constant level of drugs in their systems.
Not Everyone is Convinced
"Narcotics have never been shown to heal anything," said Dr. Bill Rosen, who specializes in physical medicine and rehabilitation at Deaconess Billings Clinic. "All you are doing is putting a Band-Aid on a wound that will never heal."
Rosen said he believes narcotics are appropriate for some pain sufferers, but he said doctors too often prescribe them for patients who could be helped in other ways.
"People come in and tell me they are disabled by their pain," Rosen said. "I say you are disabled from your inability to cope with your pain."
While it is important to take reports of chronic pain seriously, he said, physicians must also be careful to address the source of the pain in addition to the pain itself.
But chronic pain is tricky to treat. In many cases, its origin cannot be identified, and doctors, who are trained to be problem-solvers, are often uncomfortable treating something they can't see.
"They want to look at a problem and fix it," Brant said.
Even when the source is obvious - such as Vickie McCormick's pair of torn spinal discs - physicians sometimes balk at prescribing narcotics.
McCormick, a patient of Nelson's, injured her back and neck in two car accidents. When she spoke to The Gazette recently, McCormick had quit her insurance job and was packing up her desk. Without medication, she said, the pain in her back and neck is unbearable.
She had not found another physician to treat her with narcotics.
"You get humiliated when you go to another doctor," she said. "They don't understand the pain. ... My life has come to an end. I wish they all could experience it. I think one hour of my pain would shut them up."
McCormick and other patients of Nelson's said they feel ostracized by the local medical community. Some who spoke to The Gazette said physicians refused to treat them, and they speculated it was because of their association with Nelson.
Not so, said representatives of both local hospitals.
"Physicians are between a rock and a hard place on this," said Dr. Douglas Carr, medical director at Deaconess. "We have been unduly concerned about abuse to the detriment of true need and appropriate use."
Doctors face conflicting guidelines, Carr said. They are duty-bound to ease patients' pain, but prescribing too much medication or dispensing it too freely can catch the eye of federal investigators.
"They (guidelines) are not all on the same page," Carr said. "If you follow state guidelines strictly, you can probably stay out of trouble with the DEA. But that is still open to question."
For that reason, many physicians are hesitant to write prescriptions before establishing a relationship with a patient.
"The physician is really under an obligation to do an evaluation," Carr said. "They can't take the patient's word that another doctor has done a sufficient evaluation."
If Nelson's patients showed up in an emergency room or urgent care center asking for refills, they were probably turned away, Carr said. Some patients might have interpreted that caution as stigma and rejection.
McCormick, Kimber and other patients of Nelson's said they are often viewed as drug addicts who exaggerate pain to access prescription drugs - something that some people undoubtedly do. But they insisted their pain is real.
Among them is Joe Meyer, who suffers from rheumatoid arthritis, an autoimmune disease that causes chronic inflammation of the joints. Upon learning that Nelson, who has been his doctor for 16 years, can no longer prescribe painkillers, Meyer decided to try to wean himself off medication.
"It's hell to have to depend on doctors and pills to have a life," he said.
Greg Wilkinson, another patient of Nelson's, was less optimistic about life without painkillers.
"I'm doomed," he said.
Three years ago, Wilkinson suffered a work-related injury to his spine in which 11 discs were damaged, he said. Pain emanates from his neck and back and affects every part of his body, including his hands.
"It's like they are someone else's hands," Wilkinson said. "I couldn't even grab my little boy's sippy cup the other day."
Wilkinson saw Nelson only a few times before the doctor was visited by the DEA, but he thinks Nelson was close to finding a treatment that could help him. During a recent interview, Wilkinson said a prescription Nelson wrote for him had dwindled to two pills.
"I'm saving them for when it's so bad I'd rather die than live," he said.
Task Force to Study Chronic Pain
Fifty million Americans suffer from persistent pain.
American businesses lose $90 billion a year because of that pain.
All the while, a debate is raging in the medical community over how to treat it.
In Montana, a task force created by the 2005 Legislature will study chronic-pain management. The advisory group is charged with evaluating current approaches to pain management and developing ways to improve health care for people suffering from persistent pain.
It will hold public hearings, consult with pain-management professionals and report to the Legislature.
The task force will be made up of health-care professionals from across the state and be overseen by the state Department of Public Health and Human Services.
Sen. Carolyn Squires, D-Missoula, introduced the joint resolution to the Legislature that established the task force. Squires, a retired nurse, suffers from shingles, a virus that manifests itself through skin rashes or blisters and causes severe pain.
"You'd be amazed at the number of people out there who really have this (chronic pain)," she said. "There's a lot of diseases that have chronic pain with them. We are trying to alert people to it."
Squires sponsored the resolution to create the chronic-pain-management task force at the behest of the American Cancer Society, which is concerned with pain suffered by cancer patients.