Will Curtailing Opioids Increase Violence Against Doctors?

Fran Lowry

March 19, 2019

DENVER — As clinicians move to comply with a national effort to curtail opioid prescribing in order to mitigate addiction and overdose risk, there may well be an associated increase in patient violence against physicians, experts warn.

In a presentation here at the American Academy of Pain Medicine (AAPM) 2019 Annual Meeting, two pain experts warned delegates of a probable increase in violent attacks and discussed ways physicians can protect themselves.

Dr W. Michael Hooten

"This is a very important topic. Most physicians know about this, but it is not talked about in a structured way. I think it is very important to make doctors aware of this very real danger and to suggest ways they can protect themselves and their staff," W. Michael Hooten, MD, a chronic pain specialist at the Mayo Clinic in Rochester, Minnesota, told Medscape Medical News.

"It's very possible that doctors will be facing an increase in these types of problems as more clinicians prescribe fewer opioids in response to the CDC guidelines," Hooten said.

"Doctors need to know," agreed David Fishbain, MD, professor of psychiatry and adjunct professor of neurological surgery and anesthesiology at the University of Miami's Miller School of Medicine in Florida.

Dr David Fishbain

"The purpose of our talk is to generate some information to help physicians identify patients who are a potential risk, and then discuss violence mitigation strategies," said Fishbain, who heads a pain medicine research group.

Opioid Murder

In 2017, Indiana physician Todd Graham, MD, was killed because he refused to prescribe opioids to a woman who claimed she had chronic pain. He was shot by the woman's husband, who later died by suicide.

The killing of the 56-year-old physician was widely reported and while it was shocking, it really shouldn't have come as a surprise, said Fishbain.

"The clues, the information, were out there and actually had been for a long time," he said.

Fishbain has researched violence against physicians, publishing his first report in 2000 and a second paper in 2009.

Fishbain was aware that healthcare professionals are at high risk for violent attacks, but he wanted to determine which factors precipitate the potential for violent behavior.

In the 2000 study, Fishbain and colleagues found that patients in the community experiencing chronic pain are significantly more likely to turn on their physician than either patients experiencing acute pain or individuals living pain-free, who served as controls.

"Chronic pain patients had a lot of violent ideation compared to acute pain patients and controls, and they also had significantly more chronic anger than these other two groups," Fishbain said.

The doctor–patient relationship was also a major factor in predicting patient violence. A positive relationship is key in guarding against patient violence.

"If you have an angry patient, generally the [doctor–patient] alliance is much less. The stronger the alliance, the less likely the patient is to target the physician," he said.

Action Plan

Illness uncertainty is another risk factor for violence.

"In general, patients with chronic pain are uncertain about their illness because 75% of them have nonspecific pain, where we can't arrive at a definitive diagnosis. This generates illness uncertainty, which can lead to doctor dissatisfaction which, in turn, is associated with potential violence," Fishbain said.

Patients on workers' compensation or individuals who are the subjects of legal proceedings or are required to undergo treatment are also more likely to be violent toward their doctor.

"If you are sitting across from a patient who does not want to be treated, is on workman's compensation or trying to get it and/or is in litigation, these should be warning signs that this patient has the potential for violence. This is what our studies show," Fishbain said.

While preventing or avoiding violence is the main goal, it is also important to know how to deal with such situations as they arise.

Mitigation strategies can often mean the difference between life and death, and educating staff on how to recognize a potentially problematic patient from the outset — and then develop some contingency plans — is critical, Hooten said.

"The majority of threats of violence in the outpatient pain clinic setting is around the provision of ongoing, long-term opioids. Clinicians should be aware that if there's going to be a problem, there's at least a 90 percent chance that it's going to be centered around opioids," he said.

This realization calls for the development of a basic plan for how to respond to such threats.

"Simply reporting the incident or having a zero tolerance policy is not enough. Clearly there has to be some type of action plan," Hooten said.

Violence Prevention Tips

A good start, Hooten said, is to ensure that the office or clinic is adequately lit, that visibility is enhanced in treatment areas, and that closed-circuit cameras are installed, as well as reducing access to potential weapons.

"Secure furniture to the floor whenever possible, secure computers to desks, use safety glass in mirrors and windows, keep scissors and needles and other sharp objects out of sight. Anything that could potentially be picked up and used as a weapon should be hidden or otherwise secured," Hooten said.

There should also be a safe assessment room, he said. "This should be a quiet, pre-designated space to facilitate de-escalation."

Staff education, including training administrative staff, is also critical. These frontline workers are often the first point of contact and are frequently the first to sense the potential for patient violence, said Hooten.

Some clinics or doctors' offices may feel safer putting together a more aggressive program. Such initiatives should include at least two nurses, two security personnel, and an administrator to facilitate accurate communication with other personnel outside the immediate clinical setting.

"The existence of an aggressive management team demonstrates a show of force, and is often enough to de-escalate a potentially violent situation," Hooten said. It's also important, he added, to document the details of every incident.

Fishbain and Hooten have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 2019 Annual Meeting: Session 307. Presented March 9, 2019.

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