This is an archived article that was published on sltrib.com in 2012, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.
The conviction and 20-year prison sentence of Dr. Dewey MacKay for illegal distribution of opioids (pain pills) provides us all with an opportunity for reflection.
He is an orthopedic physician who developed a pain medicine practice with suboptimal oversight. He was convicted of distribution of a controlled substance resulting in death. Although I have no insider knowledge of the charges or trial, I do have insight about the issues and complexities of pain management.
Pain is an interaction between injury and the emotional processing of the threat or harm. Sometimes there is an obvious injury, like a burn, and other times the causes are nebulous, as in the case of low back pain or headache. Emotional states like anxiety, fear or depression and coping skills are major predictive factors in outcome.
Pain remains a personal, subjective experience and cannot be like other things in medicine, such as blood pressure or sugar level. Functional outcome and perceived pain level remain our measurement tools. Our tools of intervention include education, exercise, injections, surgeries, coping skills and medications.
Multiple medication types are available for pain control, including anti-inflammatories, antidepressants, seizure medications and opioids. All are effective in some people, but none is effective for all people.
Opioids, although effective, can cause a life-threatening side effect of respiratory depression, i.e. reduced or absent breathing. This side effect is more common in higher doses and in people with sleep apnea, obesity or lung disease.
More risk occurs when opioids are combined with benzodiapems (anxiety medication like Valium, Ativan or Klonopin), sleeping pills (Ambien) or with alcohol. Knowledge about these risks is evolving, and they have been better understood over the past decade. Even those without risk factors can be involved in fatal overdoses.
Opioids also have the potential for addiction. Those at higher risk include people with current or prior addiction to drugs, alcohol and tobacco. Those with mental health issues, drug-abuse history, anger and impulsivity are also at higher risk.
Pain medicine is the intersection between injury and health, coping and withdrawal, function and disability and addiction and personal responsibility. Injury magnitude often does not predict outcome as well as the mental health profile does. However, some people with excellent mental health profiles will develop chronic pain and some people with mental health issues will recover fully.
Those at highest risk for chronic pain are the same people with the highest risk of addiction and abuse.
Patients have the personal responsibility to disclose to their physicians addiction history, medication usage/substance abuse and mental health issues. Physicians have the responsibility to ask these hard questions.
It is not easy being a person in pain, disabled or addicted. It is not easy being a physician dealing with people in pain. Excellent outcomes are never guaranteed. Individual variation is the norm. All medications have side effects. People die.
Pain management is an evolving field, but most people, at sometime in their life, experience pain control issues.
We must be compassionate but responsible with each other. I hope in the years to come additional non-addictive pain medications become available, but at this time opioids remain the most potent and the most prescribed.
It seems odd that public comment with this case has been limited, but there is a fear among physicians that we may the next group targeted.
Witnessing another physician prosecuted and humiliated creates an environment of fear. This may tip the balance away from adequately treating pain.
I hope that when I am injured or ill, my physician will not be afraid to adequately treat my pain.
Michael Jaffe is a Salt Lake physician and president of the Utah Academy of Pain Medicine.