Q&A with Dr. Doris Cope, Part 2: Pain doctors need better tools to track addicts
Last week, Antidote spoke with Dr. Doris K. Cope, a seasoned anesthesiologist and pain medicine specialist from the University of Pittsburgh Medical Center who is one of the voices behind the new Life Line to Modern Medicine campaign from the American Society of Anesthesiologists. Cope talked about differences between pain management and pain medicine, the different degrees of pain and the common misconceptions about how to treat it. She also talked about Michael Jackson's death. As a professor and vice chairwoman for pain medicine in the Department of Anesthesiology at the University of Pittsburgh Medical Center, Cope has published extensively about anesthesiology and pain care.
The first part of the interview appeared on Friday. The interview has been edited for space and clarity.
Q: Michael Jackson's doctor ran a sleep clinic, and, like the pain centers, these have started to pop up all over the country. Can there really be that many people who have a medical condition that is preventing them from sleeping properly?
A: There is a legitimate specialty of sleep medicine. A number of people have sleep apnea or other sleep conditions. They are usually overweight, and when they lie down everything in their airway collapses. Some of these sleep centers are set up to diagnose that.
Q: But not all of them. Could pain medicine doctors be accused of masking the problem that is causing the pain? If you are treating the pain, you are hiding the symptoms, and by hiding the symptoms, you are avoiding the underlying problem which may, in fact, become worse?
A: That's kind of a misconception. The old concept is that pain is a symptom and not a disease. I had a discussion with a primary care doctor in his 80s who said that pain is just a symptom. I told him that is just not the case. Chronic pain serves no good purpose. It's not alerting you that your hand is in the fire and you better pull it out. Chronic pain takes on a life of its own. There is a memory of chronic pain in the spinal cord, in the brain and in the neurotransmitters at the molecular level. If we can break that signal, we can break the cycle of pain.
Q: In some ways, does the field of anesthesiology bear part of the responsibility for the rise in painkiller addictions in this country? Drugs like OxyContin and propofol, the drug that played a role in killing Michael Jackson, are so easy to administer and so powerful that people can quickly become addicted.
A: Anything that's powerful is going to have a negative effect. If it didn't work at all, it would be like a baby aspirin. There's also a difference between addiction and habituation. Addiction is psychological dependence on a drug or substance or experience, like gambling or sex or shopping. That's why anyone who uses chronic pain medications needs to come off them slowly. Years ago, my grandmother had pancreatic cancer, and I remember her crying out in pain. They said, "We don't want to give her painkillers until four hours have passed because we don't want her to become addicted." Then the medical profession swung the other way where some were perhaps too quick to prescribe. Now, at the ASA, we try to promote a judicious use of opiates. As pain specialists, we do urine screens. We do pill counts. You have to have a relationship with the patient. The medications will only be effective if they are part of a larger treatment plan.
Q: I guess that's what I'm getting at. Don't so many doctors continue to not have a relationship but to just write the prescriptions and hope that the patients will keep coming?
A: I saw some data recently that there is much more misuse of prescription pain medicines than illicit drugs. People are going to open houses and taking pain meds out of the cabinet. Young people are taking them from their grandparents. As a physician, you are not a policeman. But we do have to be judicious. I have had to call social services when I felt that medicines I was prescribing were going to the caregiver.
Q: What was the situation?
A: This old woman was very crippled with arthritis, and her son was insisting that she be prescribed a certain amount of very specific drugs. I told him, "Your mother is in pain, and we need to assess her specific needs." He didn't even want me to talk to her alone, wouldn't allow it. He also would not allow me to admit her to the hospital. I found out later that he was just taking her from clinic to clinic trying to get pain meds.
Q: What happened as a result of your call to social services?
A: There was an investigation, and I got a very threatening, angry call from him about why I had interfered. I have occasionally had obscene phone calls. Another patient wanted his mother to have these specific medications. I called the mother, and she told me that this guy was selling pizza and OxyContin. You get the special of the night with comes with some painkillers. I have heard of people selling drugs out of Chinese restaurants. You place your order for your food and your drugs at the same time.
Q: Time and again in doctor disciplinary reports across the country, I see the same patterns of physicians who are either hooked on pain meds they prescribe themselves or they are getting patients hooked because they aren't doing complete physicals or any other due diligence to discern between true pain cases and addicts looking for a fix.
A: My guess would be that very few of those doctors were true pain specialists. We are not the problem. Our health plan looked at prescribing patterns in our area and found that it was the primary care doctors who were prescribing more painkillers. Pain physicians were prescribing in smaller quantities. The problem is the people who doctor shop and go to multiple doctors and pay cash for the drugs. Even the insurance companies will say, "You can't get this refilled so soon." The doctor doesn't know what to do so they give them what they want. Then you have a problem. If we could have a national registry and have a record of who gets all these drugs, then something might pop up in the electronic health record that said, "This person already has seen three other doctors and been prescribed the same drugs in the past two months." But a national reporting system is expensive and who would pay for it? I think that 99.9 percent of physicians would make the right decision if they had the right information.
Q: Doesn't the DEA already gather this data?
A: They may gather it, but someone has to look at it and analyze it. There's not the manpower to review all this data.
Q: I'm not sure there would be that much manpower involved. I spoke with the DEA not too long ago for a story, and I was surprised by the volume of data that they collect. If patients were logged in with their Social Security Numbers, the tracking would happen by itself. The computer would do all the work. What can pain docs do to help their patients avoid becoming addicts or to spot addicts who are doctor shopping?
A: We do a pretty good job. Although we can't see every prescription that has been written for them or filled, we can look at their records and see quite a bit. I can see whether they have had to go to the ER for an acute injury. I can look at their X-rays. I want to see the whole picture on this patient. I have to be convinced it's warranted before I write a prescription. If someone comes in and says, "Give me Dilaudid," that's a bad sign. A drug is not a diagnosis. We're not a McDonald's. "I want six Dilaudids and an OxyContin."
Q: What do you recommend for people looking for a pain doctor? What sort of background research should they do?
A: Whatever your pain complaint is, you need a medical evaluation by your primary care provider or whoever you are seeing. Usually those doctors know what resources are available and know the reputations of the pain medicine specialists. The most important thing we have is our reputations. If I take good care of a doctor's patient, he will send me more patients.
Q: What sort of questions should patients ask of the doctor?
A: I would ask, "Do you have board certification in pain medicine?" If they have that, they have the training at least. You have to be certified every 10 years, so ask if they are keeping it up. You can talk to other patients, too. Have they had good success with this doctor? Are they just given a prescription and sent away?
Q: This didn't happen, apparently, in the Michael Jackson case. He hired a doctor who was not an expert in pain medicine and was not even board-certified in his chosen specialty, cardiology. What did you see in the reporting of that case that you thought helped illuminate the importance of good pain care?
A: Michael Jackson clearly knew what he wanted. He knew the kind of treatment and selected someone, as I understand it, who was a full-time physician to do what he wanted. Michael Jackson did not go to a university health center and say, "I want a professional opinion on sleeping and pain care." There are some people who can get doctors to do exactly what they want. I would not go to a cardiologist for pain care. It was embarrassing for the medical profession that a physician would give an anesthetic drug like propofol to a patient in their home and, on top of that, use it inappropriately. It's an embarrassment for me as a physician when another physician practices outside the standard of care.
Q: So the criticism in the press of Dr. Murray was warranted.
A: I don't know of any cardiologist in my experience who would go to your house and give you IV anesthetic medication. I had never heard of this until this case.
Q: What are some of the warning signs for a reporter that someone who is putting himself out there as an expert is perhaps not?
A: If I live in a small town in Mississippi and a new doctor comes to town who is offering some new treatment, I might write a story about it. People need to know what's new in medicine. I am on the board of the Allegheny County Medical Society, and people put in questions about what to do about back pain. They want to know who in my community can help me. On the national level you have to assume you have medical writers who know who the thought leaders are. The pharmaceutical industry will promise all these great cures that may or may not be great but haven't stood the test of time yet. With physicians, you need to find out about their reputations. Again, are they connected to the greater medical community or are they out there on the edge or practicing outside of their field? I had a urologist say to me, "I have a friend who would like to spend a couple of weeks with you and learn to do pain medicine." I said, "That's great. I have a friend who is a nephrologist who would like to spend a couple of weeks with you and learn urology." Pain medicine requires specific knowledge and specific experience.