DEA and Doctors Working Together
In 2002, we developed the Share the Risk model as an interdisciplinary approach to the most challenging patients in medicine—patients with chronic pain.1 The fundamental premise of the Share the Risk model is that no clinician, no matter how well educated, competent, compassionate, committed, or meticulous, can adequately meet all the needs of patients with chronic and intractable pain. Instead, the Share the Risk model calls for a multidisciplinary team approach for optimal pain management.
Started in San Diego, the Share the Risk model is a work in progress. The goal is to bring together the various resources in the community—clinicians, as well as representatives from biotech/pharmaceutical industry and the Drug Enforcement Agency (DEA)—to address the many groups affected by pain and pain management. On a national level, the model was the catalyst for the development of an educational program called Emerging Solutions in Pain (ESP).2 ESP’s mission is to “address some of today’s most critical issues in pain management.” According to the ESP Website, “These issues involve balancing fundamental rights of patients and clinicians with the challenge of risk containment for opioid misuse, abuse, and addiction associated with medical prescribing and use of controlled substances.” Like ESP, the Share the Risk model helps pain management healthcare professionals overcome these challenges by providing practical tools, resources, and courses to help navigate these issues.
Although these goals have not changed, the political atmosphere in which we practice has. This has led the authors to try and work together with the DEA in Southern California. In the past several years, the authors have held several meetings to educate health professionals about Share the Risk mission. These meetings, attended by between 50 and 65 healthcare professionals, have been the most passionate and emotional meetings that any of the coauthors have ever observed. We are not aware of other DEA field divisions with the same level of interaction with healthcare professionals. This article summarizes some of the problems clinicians who treat chronic pain patients face and offers strategies to help address these problems.
Shift in Perceptions About Opioids
There have been multiple newspaper articles and television programs questioning the use of opioids for pain management over the past several years. Perhaps the most noted among pain specialists was the front cover article in The Wall Street Journal in December, 2012, that featured an interview with Russell Portenoy, MD, one of the leading proponents of improving pain management (and access to opioids) in noncancer patients.3 Acknowledging in the interview that standards and recommendations regarding opioids have changed, Dr. Portenoy said: “Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did.” He added, “We didn’t know then what we know now.”
Dr. Portenoy noted that long-term clinical studies about the effectiveness of opioids do not exist. “Do they work for 5 years, 10 years, 20 years? We’re at the level of anecdote,” he said.
Even with these doubts, Dr. Portenoy still credits opioids with providing pain relief and benefit in carefully selected patients, including his own mother who has taken hydrocodone to control arthritis for 17 years. “If you insist on regulation, then you’re consigning my mother and many millions of people like my mother to live in chronic pain,” he noted. But there is little research to show whether patients who embark on long-term opioid therapy will ever be able to stop.
Misuse and Abuse of Opioids
Abuse and misuse of prescription opioids has become a public health crisis. Prescription drug overdose as a cause of death has tripled since 1990, and has surpassed motor vehicle accidents. In 2010, overdose deaths from prescription opioids (16,651) far exceeded those from heroin and cocaine combined.4 Overdose and death risks increase significantly with higher doses of opioids.
There have been multiple articles over the past few years about physicians across the country who have been investigated because of opioid overdoses occurring among their patients. The Los Angeles Times reported that there are physicians in Southern California who have had 14 or more patients die due to opioid overdoses.5 But perhaps the most disturbing report has been the investigation of Lynn Webster, MD, the Immediate-Past President of the American Academy of Pain Medicine.6 Dr. Webster serves as a leading expert in the safe use of opioid pain medications. He created the Opioid Risk Tool (ORT), an assessment tool to identify patients who are most likely to abuse opioids.7 Presently, he is under investigation by the DEA, which raided his Utah Clinic in 2010. Dr. Webster and associates treated thousands of patients and approximately 20 patients died of polypharmacy overdoses. Dr. Webster remains a highly respected expert in pain management, and has received broad support from the pain management community.
These high profile articles raise questions in the minds of patients, clinicians, regulators, and law enforcement about the safety of opioid pain medications. Conversely, the media explosion has had a powerful, negative effect on the pain management community. Clinicians wonder, ‘If I prescribe opioids, will I become a target of the DEA?’ Out of fear of being targeted, many pain management physicians, family practice doctors, and other clinicians are refusing to take care of people in pain or are simply refusing to prescribe opioids. The unwillingness to treat these patients is simultaneously occurring at a time when the Affordable Care Act is attempting to provide greater coverage and access to healthcare to all Americans. In the end, more and more patients suffer—and that number is only expected to grow. With the aging population, 1 out of 2 people over 50 years of age are expected to suffer with chronic pain.
There are several views of this difficult situation. Healthcare professionals who treat pain patients and prescribe medications fear the DEA will make them a target. On the other side, the DEA enforcement strategists are trying to strike the proper balance between access to opioids for legitimate patients and preventing drug abuse and diversion.