Opioids and the Predilection for Violence in the Pain Clinic: A Physician’s Perspective

Abstract

Pain physicians, more so than any other specialty, interact with a patient population that is significantly more likely to engage in violence. In this commentary on the article “Patient-on-Provider Violence in the Pain Clinic” by Judy George, we echo some of the points mentioned in the manuscript. There needs to be a better system in place to identify and to deal with problem patients seeking drugs. Although there has been a push recently to move away from opioids with a patient-specific multimodal analgesic treatment plan with a focus on interventional pain procedures, opioids are still a part of the pain physician’s practice. The medical community must stand behind ensuring these doctors and their staff can practice in an environment that is safe for them and the patients they are caring for. This response fully complies with ethical guidelines. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.

Dear Editor,

We read with great interest the recent article by Judy George, Patient-on-Provider Violence in the Pain Clinic [1]. The article brings forth the reality that “Pain clinicians were likely to encounter violent patients, including assaults and threats revolving around opioid treatment [1].” The article details the 2016 murder of Todd Graham, MD, an Indiana pain physician by the husband of a chronic pain patient. Dr. Graham refused to prescribe the patient opioids and was subsequently killed because of it.

The pain physician, more so than any other medical professional, deals with a patient population with a predilection for violence. The article reports “Chronic pain patients also are four times more likely to express homicidal ideation toward their physician, which is linked to several factors including doctor dissatisfaction [1, 2].” With new government regulations regarding prescribing opioids, the pain physician has evolved as the primary doctor dealing with opioids. Although much of the practice has gone towards the multimodal analgesic regimen with a focus on the interventional realm with implantable devices, injections, and non-opioid therapies, there remains a substantial chronic pain population that continue to seek opioids as their only “treatment” for their pain.

Opioids are some of the most addicting substances based on neurophysiologic and euphoric properties. A large portion of chronic pain patients were inappropriately prescribed opioids decades ago as a reflection of the time as the primary option to treat pain. The issue today remains that a lot of these patients genuinely believe that opioids are the only way to “treat” their pain. Long-term opioids shut down endogenous opioid production and result in dependence and central nervous system withdrawal when stopped abruptly. Although there are some patients where opioids are appropriate and provide substantial functionality and very low risk of addiction, there are others that are resistant to finding alternative therapies and truly taking the time to understand that the negatives of chronic opioids do outweigh the perceived benefits. Although healthcare is slowly trending away from opioid prescribing for non-cancer and non-acute postoperative pain, this issue will continue to persist for years to come.

Conclusion

It is imperative for the offices of any physician, pain or not, who prescribe opioids to have a proper security protocol so providers can feel safe, especially when there needs to be a conversation with their patient that opioids may not be the best option for them moving forward. A nationwide protection policy must be implemented to stop the violence and targeting of these physicians and their staff. More security in these offices, a no-tolerance policy for these troublesome patients, and flagging these individuals as potential threats are a great start to ensure a safe environment for everyone, including our patients. Our job as healthcare providers is to advocate for our patients, and if this happens to include finding alternative options to opioids, we should be able to have this conversation without fear of harm or retaliation.