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Pain Management in the Crosshairs: A CAP Roundtable, Part 2

Guests: Dr. T. John Hsieh, Dr. Medhat Mikhael, Dr. Charles Steinmann, and Dr. Jae Townsend
Moderator: Carole A. Lambert, MPA, RN

We continue the conversation with Dr. Hsieh, Dr. Mikhael, Dr. Townsend and Dr. Steinmann, which we began in the May issue of CAPsules.

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CAP: Dr. Hsieh, you have talked in the past about how patients on pain medication long-term are changed. What have you observed?

TJH: My experiences with my patients has prompted concerns about the cellular, the metabolic effects of prolonged pain medication administration. If you have ever seen and evaluated a patient who has been on long-term narcotics, your assessment will reveal how they have changed. Research shows that the changes start at the cellular level and get amplified when you lead up to a whole. The patient’s perception of society changes. Daily behavior changes. Rounding out a comprehensive assessment is challenging, but getting one makes it possible for a physician to make a difference with patients. When a patient comes to you saying they want to be treated for his or her pain, educating them about what’s happened to them, talking about what their goals are, and managing their expectations will be key.

MM: I agree. We have a step-by-step approach. I may evaluate a patient who has not been on narcotics before and feel that this patient is a legitimate patient to be on pain medications whenever needed. 

I have to have an agreement with the patient with multiple points: I am the only prescriber. They cannot ask for early refills. They cannot share these medications with anybody. They cannot take medications from anybody else. They are very centered about using one pharmacy only. The prescription comes only from us. They agree to have a random urine screen done on our premises.

We also make sure we obtain informed consent with detailed discussion of possible side effects. We run a CURES report. We manage pain patients in a tight fashion. The patient understands that we are monitoring them closely and that we’re working towards treatment approaches to help their pain and get them off medications

CS: We’ve learned some lessons here at CAP that we can carry forward to protect physicians and patients. The first thing is documentation. Whether it’s pain management, surgery, or just medical care in general, it may be difficult but it has to be done. Communication is probably the second most important thing, and that comes back to the patient’s goals and expectations. For instance, there are a lot of patients who will come in having had chronic back pain for many years and may have had laminectomies. Their pain levels when they come in are an 8/10. We talk about trying to make a goal of 4/10. If we can make a goal of 4, that will be a victory and we talk about that, and 95 percent of the time they’ll say if I get it to a 4, okay, I might be able to live with that and that would be a victory. Well, that to me is an achievement and if you get better than a 4, then you are a super winner and they love you forever. So having expectations that are within reason, using available tools and controls, and effective communication and documentation are very, very important.

Also, I think a lot of things can be covered without narcotics. I am more and more impressed as time goes on about the use of anti-inflammatories. Certainly, going back to the operative situation and using the anti-inflammatories for certain surgeries, once you know that there’s not a bleeding problem, Tramadol has been and is a terrific drug. Toradol is also a terrific drug especially for use with laparoscopes. 

Let me just say that we hear there is a drug problem now, as if there wasn’t in the past with opium and cocaine. There are a lot of things in motion here, and medicine is still an art, not a science.

MM: A big problem with a big impact is that a lot of payers have issues or problems covering behavioral health and addiction treatment. So you get a patient who agrees with your terms, agrees with the plan, and accepts the risks. The patient may be fearful but agrees that they need help. Then you go to the health plan and say, “I need a psychologist to see the patient,” or, “I need a psychiatrist to take on that patient because as we get him off narcotics, he’s going to be depressed,” or, “I need an addictionologist to help me to get him off that stuff he’s been on.” Then all of a sudden, you find that behavioral health and addiction medicine are not covered benefits for this patient’s insurance. It’s a challenge for us as clinicians as we try to take care of patients and practice safely.

CAP: Dr. Townsend you see people. They have general anesthesia. They come out, they have finished their procedure, but you must be interacting with families a great deal. What about the patients who are not on the census — the families?

JT: We approach this as a constellation of biopsychosocial spiritual factors. When we treat a child, we don’t just treat the child — we treat the child’s family, as well as his or her social environment. It is absolutely essential to have everybody on the same page. For children, we get a lot more mileage out of a preventive for pain, and I would say the same is for adults. You know, we talk a lot about pain management, but we need to have lively and abundant conversations about pain prevention. So, we do lots of things in anesthesia such as regional blocks to prevent the experience of pain, so you don’t have those apparent pathways that get set up whether it’s wide dynamic range neurons or complex regional pain syndrome. These are things that may happen when you have a painful experience that’s not prevented or initially managed well.

TJH: As chair of CAP’s anesthesia/pain management risk assessment peer review, I can say we’ve learned a lot. I have been doing case reviews for more than 10 years, and I know I am more careful in my own practice. What I have seen over and over is that the number one cause of lawsuits around pain management is failure to manage patients’ expectations. Patients’ expectations are different from their physicians’ expectations. And patients’ expectations of pain management physicians are different from their expectations of other physicians. This is where communication in all its forms— education, informed consent, pain contracts – is so important. So when patients feel they haven’t had all their questions answered, that the physician has kept information from them, that there’s a lack of transparency, then the patients were more likely to file a claim. That’s my perception number one.

And my perception number two is the critical importance of documentation. A lot of physicians for one reason or another fail to document what is going on with the patient. They get busy. They forget. For whatever the reason, they fail to document exactly what happened, when it happened. Rarely — and it never ends well — a physician will add to or edit the record. That doesn’t happen too often, but we have seen it. So, at the end of the day, document as truthfully as possible, and as carefully as possible.

And finally, when an issue comes up, it’s always a good idea to call CAP’s hot-line and a talk to a risk management and patient safety specialist. They will give you a very concise and correct pathway for you.

CS: That’s excellent. I’m glad you brought up the CAP Hotline because that is a unique thing that we do and believe me, it is very very helpful for the clinicians.

CAP: We have just a few minutes for final thoughts

TJH: Just a caveat for all of us to think about: all of us involved in healthcare — clinicians, entities, systems, industry partners — share the responsibility to work together to reverse the substance use and abuse patterns. This means, among other things, being willing to pay for the professionals, the tools, the alternative treatments. It means being willing to advocate for those resources. No one factor is responsible for the rates of addiction and the rates of death by overdose. No one factor is the answer. Everybody needs to be part of the solution.

JT: I just want to dovetail on what was said about documentation. Your record and what you document is what happened. If you didn’t write it down, it didn’t happen. So as a treating physician for pain patients, it is imperative to always keep a record.

MM: I always tell students and young doctors: treat your patients exactly like you’re treating your own family members. If you think that way all the time, patients not only will love you and trust you, but your liability will be reduced. Definitely this is in addition to what others have said: document, document, document.

CAP: Dr. Tom Nasca, CEO of the Accreditation Council on Graduate Medical Education, said in a presentation a couple of weeks ago, that we are preparing the prescribers of the next 40 years. So everything that we do with the young physicians, young clinicians who come within our orbit, is going to pay off in the future for a more balanced approach.

Dr. Townsend, Dr. Mikhael, Dr. Hsieh, Dr. Steinmann, thank you all so much and I know that folks who listen read about the roundtable are going to be challenged and reassured by everything you’ve contributed today. 


Carole A. Lambert is Vice President, Practice Optimization and Residents Program Director for the Cooperative of American Physicians. Questions or comments related to this article should be directed to