We have heard a lot lately about the opioid epidemic going on in the United States. For those physicians who treat patients with chronic pain and are on the forefront of the opioid crisis, the issues aren't just headlines, but a reality.
This opioid issues recently hit home when a well-known Indiana physician, Todd Graham, MD, was killed outside his office by Michael Jarvis, the husband of a patient to whom he had refused to prescribe opioid pain medication. According to an article about Graham's death, he told the patient that opioids weren't the appropriate treatment for her pain, but the patient's husband insisted on a prescription. Graham allegedly held his ground and the argument with Jarvis escalated. Graham supposedly pulled out his phone and started recording audio until the couple left. Graham did not file a report or take any other action. Jarvis later returned to the medical complex without his wife (and supposedly without her knowledge) and argued with Graham before killing him.
The reasons behind Jarvis' actions are not entirely clear, but the dispute clearly related to the prescription (or refusal to prescribe) opioids. The Jarvis scenario creates a frightening possibility for physicians who face the daily fear of becoming a victim when they choose to deny access to opioids. In this particular case, the killer was the patient's spouse, which further widens the possible aggressors as it relates to opioid denial.
If your practice prescribes opioids, it is essential to have a firm plan on how the practice handles its pain patients and the policies it maintains on opioid prescriptions. Recent guidelines put out by the CDC (www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm) can further help in the progress of developing a plan. These guidelines are intended to improve communication between clinicians and patients about the risk of using opioids for chronic pain, as well as to improve safety and effectiveness of pain treatment and to diminish some of the risks associated with long-term opioid therapy. These guidelines are intended to minimize overdoses and deaths, as well as patient addiction.
The CDC guidelines do not touch upon the realities of how physicians on the forefront can physically protect themselves against patients who seek to do harm. I have clients who travel to and from work armed. I have clients who have switched specialties to avoid any issues related to opioids. There are, unfortunately, no perfect answers on how best to protect healthcare providers who are trying to help patients in chronic pain or who might have an addiction.
Here are some ideas to consider on how we might better protect our providers:
1. Every healthcare employee should be provided with behavioral management training. For those providers that are more likely to encounter conflicts with patients, a more specialized level of training should be offered.
2. Providers should learn better skills for interacting with patients. For example, it is recommended that providers pause more to listen and solicit responses from patients, while avoiding complicated terminology or defensive language. Providers should learn to differentiate between angry, frustrated or difficult patients and those who may actually cause physical or emotional harm (observing behavioral cues). Some experts even recommend asking a patient directly: "Do you plan to harm me?", and thus convey that violence is unacceptable.
3. Providers should be trained to spot aggressive behavior and not to tolerate it. Signs of aggression can include cues that an untrained individual may not notice. A provider should leave or get help immediately at the first sign rather than trying to handle a situation on their own. Training might include tips on maintaining physical distance, not turning your back on a potentially violent person, staying between the door, and the potentially violent person and even removing personal items that can be used as weapons (tie, stethoscope).
4. Practices might consider hiring a security officer who can be actively involved when personal safety is felt to be at risk (where applicable). Other physical protections might include panic buttons, metal detectors, and other precautions (which may or may not apply in your state and to your particular practice).
5. Communication among staff about patients who have created concerns in the past is key. Threatened provider should share and document interactions and the practice should seek legal advice on how best to handle the patient (i.e. termination from the practice, reporting to police, etc.). Patient records can also be tagged for past behavior, suspected addiction and other factors.
6. Help patients to help themselves! Patient education materials, documentation on available resources for addiction, space for a patient to be along to cool down, and even a telephone to call a loved one for advice might make a difference.
Make no mistake that Graham, and other physicians and providers who may be killed under similar circumstances, are victims of the opioid epidemic. The only question now is what we can do to prevent such a tragedy from reoccurring.