“I would not recommend that you go into pain medicine… find something else rewarding to do.”
The honesty of that statement just exploded from my mouth – like it has been welling up to be spoken (or shouted) for many months.
I am at my clinic at Tulane University Medical Center, where for many years I have worked closely with senior / 4th year medical students who are about to graduate. These are students doing an elective in Ambulatory Medicine – a ‘hot topic’ for the American Academy of Medical Colleges. They have, therefore, completed all the core rotations – medicine, pediatrics, surgery, and the like. In short, they are as well trained as interns and residents. In fact, they are even better than interns and residents because none of the biting hours of internship have ground down their optimism and dedication (yet)!
These students have worked closely with me in my Tulane clinic where we continue to prescribe opioid-containing pain medicines to patients with responsive conditions. Of course, my clinic is also trying to integrate the lessons of the CDC Guideline [if you don’t already know this web address by heart, here it is] and other treatment recommendations as much as possible.
Students have found this rotation rewarding enough that it was featured as a locally-started innovative educational program through the Tulane .
With this good publicity, you would think I would be singing the praises of our field of pain medicine to students, encouraging them to go into an area of organized that is valued (or at least highly featured) by our society. You would also think I would be crowing-on incessantly about the practice of pain medicine / pain management making an enormous positive contribution to the essential nature of ‘doctoring’. That essential nature being the improvement of the quality of life for patients when the condition they suffer from cannot be simply cured .
Rather, I have felt totally under siege – panicked – and worried that the ‘government ninjas’ will raid my clinic soon too. What not? They seem to have raided many other pain management clinics in the area. What makes me so special (answer: nothing)?
I am sure some “bad actors” have been rounded up in these pain clinic raids. But physicians, pharmacists, and clinics that I worked with for many years in providing pain care for complicated patients have also been ‘raided.’ These raids have left their patients scrambling for replacement providers and their colleagues (like me and you) in a panic that they will be next.
One closure is the recent law enforcement raid of Wilkinson Family Pharmacy in Chalmette, LA. This raid was carried in many local news outlets.
I certainly did not know of the shenanigans that have since leaked out into the press accounts. What I do know is that several complicated patients – with cancer, with organ transplant, and with other painful afflictions, have used Wilkinson Family Pharmacy for years. I also can affirm that the pharmacists and employees at Wilkinson were willing to go ‘above and beyond’ for many of my patients, giving me time to discuss the case with them and giving my patients time to ask questions about their medications in a way that the chain pharmacies just DON’T do!
Last Friday, I was furiously rewriting prescriptions for all the medications (controlled, not controlled – all of them) for my patients whose prescriptions were at Wilkinson’s and are now lost to the wind. St. Bernard Parish – an area that has both a history of intense drug abuse as well as intense lack of access to healthcare services – just lost one more service provider.
There have been other raids that have not made the media –so I don’t want to document the details because the information I am getting is through the unreliable grapevine. But, taken together, it leads me to wonder if the government has decided that our entire field of pain medicine / pain management is a scourge to society and that it is going to shut down that field, one provider at a time. The only way to avoid this fate – get out now anyway you can with your license, assets, and sanity intact.
Adding another element to this whole situation is the fact that most prescription alternatives to opioid containing medications don’t work well at all in relieving pain – almost always no better than placebo. An article, Trial of Pregabalin for Acute and Chronic Sciatica, published recently in the New England Journal of Medicine, agreed with several previous non-biased trials that Lyrica is no better than placebo for sciatica.
There also have been countless articles (unless you work for Cochrane Clinical Reviews – then you can count that high) on the real risks to life itself caused by long-term use of NSAID anti-inflammatories for pain control (see e.g. ‘TIME Health’ article on 03/15/2017 titled Common Pain Meds Are Linked to a Higher Risk of Heart Problems).
This whole situation has led to a situation where that safe and effective alternatives to opioids for the treatment of chronic pain are so sorely needed that the government is imploring pharmaceutical companies to spend billions more on looking for these types of drugs. As this April 17th article from the Detroit News does a good job summarizing, Big Pharma has responded with many trials. But, trials do not equal success. To this point, the quest for non-addictive AND highly-effective medications for the control of chronic pain is more in the realm of a Star Trek-like hope for future medicine. Instead, we labor and learn in the real world of actual modern-day medicine that has lots of non-addictive treatments for pain. But, are they highly effective to our patients as a whole? Using the same data yard stick that was used for compiling the CDC Guideline, the answer would be resounding “NO”!
If you think this whole situation has been terrifying for us, imagine for our patients! On March 13th, pain patient Alessio Venture wrote an honest and forthright assessment of this situation from his own vantage point – a person with horrific chronic pain whose only relief has come from opioid-based pain medications. Writing for Pain Network News, Mr. Ventura describes pain from 17 surgeries since 2008, including major back surgery, rotator cuff repair, biceps tendonitis, knee surgery and hernia surgery. He describes thorough and failed trials of Lyrica, Cymbalta, chiropractic, injections, NSAIDs, and acupuncture that led to failed pain relief and new problems like dramatic weight gain and depression.
Mr. Ventura is currently on Oxycontin and takes testosterone for the hormone changes caused by Oxycontin, and he has a life of quality. At least a life enjoyable enough to raise four children and work for decades as an engineer for Bell Labs. Like many patients I have treated, he describes his response to opioid-based pain medicine (even with its risks and side effects) as a “miracle” – especially when compared with how dismally the alternatives worked for him.
He is far from alone. In a recent survey published by Pain Network News of more than 3,000 patients with chronic pain, about 84% said their pain and quality of life has worsened since the new CDC Guidelines were implemented. 42% said they considered suicide because of how poorly their pain was treated, and 22% said they’re hoarding opioids because they’re unsure they will be able to get them in the future.
Just to show this patient dissatisfaction has not been artificially manufactured by Pain Network News for its own aims, there have been plenty of other articles about how terrified pain patients are. Just look at these recent news reports from several states including Ohio and Maine, from HMOs such as Kaiser Permanente and nationally in magazines like Reason Magazine.
These articles point out that there have been glaringly needed reforms to opioid prescribing in some situations, but the wholesale campaign now engaged in has created countless desperate and frightened individuals who have seen a life-preserving form of treatment snatched away from them with disastrous consequences.
This leads me back to my student – who has worked along-side me for two months. On our last day together, he tells me that his experience in my clinic has been the best experience he has had in medical school. He tells me that the patients he has encountered in our Tulane clinic feel heard, validated, and respected by our program. The student has been impressed with the several stories he has heard from patients about how they were considering suicide “before the treatment with Dr. Potash” and how their lives are immeasurably better now. The student tells me “this is why I went into medicine in the first place… this is what makes all that student loan debt seem worthwhile” and asks me how to best pursue a career in pain medicine after training.
I have had students ask me this before and I have been pleased to direct them towards residency programs with strong training in pain management for residents as well as fellowship opportunities. But, this time, I blurted out “I would not recommend that you go into pain medicine… find something else rewarding to do.”. The student looked shocked and started apologizing for whatever offense he had caused. He presumed that was why I was sternly directing him AWAY from a career in pain medicine – that I must have found him an unworthy candidate to follow the same patch I had chosen.
It took me some time, but I was able to explain to him that he is a great student now and will be a great doctor in a few short months. However, I did not want to feel responsible for him choosing a field that has been so crushingly hard to practice in over these last few years – a field that seems to be collapsing around us under the gravitational weight of criticism and castigation. I didn’t want to be responsible for his sleepless nights, having has so many fitful nights myself recently. I wanted, above all, for him to feel that he was practicing in an area of medicine that was respected by both colleagues and society as a whole and I don’t feel that way about the field of pain medicine / pain management currently.
This column may seem like the worse advertisement ever written for attending our September 25th annual conference (and our first time hosting our conference in conjunction with the Southern Headache Society).
Nothing is further from the truth!
This column is really an urgent call to attend this meeting – to send in your registration now and participate in the conference enthusiastically… like groupies for Hamilton! You may not need to sing every line at the conference (truth is – there will be zero singing), but there has never been a more urgent time for the networking, education, and advocacy that our conference will provide.
We are practicing a time of profound professional uncertainty. Yet we still have unbreakable obligations to our patients. Their lives would be unequivocally damaged if we just ‘cut and run’ away from our practices. Although we face enormous challenges – with new ones seeming to spring up daily – let us meet these challenges together. As Ben Franklin said, “We must hang together or surely we shall hang separately”.
See you in September!