Pain is generally considered to be the most common reason our patients come to see us. Yet it's a phenomenon that we fully don't understand and wondered varies lightly from patient to patient. With regard to prescription of potent painkillers like methadone, does the often cryptic nature of pain warrant additional pain management training for practitioners ordering these meds? You are listening to ReachMD, The Channel For Medical Professionals. Welcome to the Clinicians Roundtable. I am your host, Dr. Mark Nolan Hill, professor of surgery and practicing general surgeon and our guest is Dr. Howard Heit, a nationally recognized chronic pain and addiction specialist practicing in Northern Virginia and an assistant clinical professor at the Georgetown University School of Medicine.
DR. MARK NOLAN HILL:
Welcome, Dr. Heit.
DR. HOWARD HEIT:
Thank you, Dr. Hill for having me on this program.
DR. MARK NOLAN HILL:
Dr. Height, are there individual differences in variability with respect to different patient diseases and subtypes in using methadone?
DR. HOWARD HEIT:
Absolutely there is. There is a new field called pharmagenetics of drugs and that has to do with the genetics that deal with the relationship between inherited gene and the ability of the body to metabolize drugs and there are variations in patients or group responses to group therapy in drug efficacy or drug safety, and we will not know the patient's response to a given drug until after its given, will it be of benefit or adverse reaction, and methadone is a perfect example of this. Its half life has marked individual variation from 14 to 40 hours. It is extensively bile transformation in the liver to the Cytochrome 450 system. The activity of the Cytochrome 50 system can vary as much as 50-fold in individuals. Another example of pharmagenetics is the medicine, codeine. Most family practitioners and internists know codeine, but codeine is a prodrug. Eating it has no intrinsic analgesic action in itself, but it gets metabolized 10% of it to morphine that gives it its analgesic action and approximately 10% of the population pharmacogenetically does not have the enzyme to metabolize codeine.
DR. MARK NOLAN HILL:
Now speaking as a pretty regular general surgeon and I am sure many of the listeners are thinking we really don't have this background that puts us at a great disadvantage to properly prescribing medications like these.
DR. HOWARD HEIT:
Well, I come back to when we were in medical school, Dr. Hill and I come back in medical school the first time that I did a spinal tap and with trembling hands, I put the needle in the lower back and I heard a "Sssss," and I thought the brains were in the syringe.
DR. MARK NOLAN HILL:
Ha, ha, ha, ha.
DR. HOWARD HEIT:
But after I did about 3, 4, 5, 6, a dozen of them, I was very comfortable doing a spinal tap and like anything else, the first time you prescribe it, the first time that you do a procedure, sure there is going to be apprehension, but then the more that you get used to that particular medication, more comfortable with it, then you are more able to use it appropriately for your patients.
DR. MARK NOLAN HILL:
Now, you read stories of physicians in legal trouble for what the government calls prescribing errors and you be actually labored with federal regulators to improve guidelines for narcotics, so what can we do, how do we really differentiate medical error in prescribing versus criminal behavior?
DR. HOWARD HEIT:
Well, I think your chart, your medical records is the key. Your medical records that if you don't document everything in your medical records, it's a figment of your imagination. Dr. Hill, I published something called Universal Precautions in Pain Medicine, its 10 principles of how to approach the chronic pain patient and also a triage scheme of which patients one should take care of and since your listeners are mainly internists or family practitioners, they should take care of the group 1 patient. That's the patient who doesn't have the disease of addiction or untreated psychiatric morbidity. Group 2 patients or patients may have these problems or these diagnoses in their past, but they are well controlled, and in that case you may want to get a consult with someone like myself, so that I could see whether your treatment plan is appropriate for that particular patient and group 3 patients are ones that you shouldn't touch with a 10-foot pole. Those are the patients who have an active disease of addiction or have untreated psychopathology. So whenever you see a patient just like you are seeing a patient who has a cardiac problem or an endocrine problem or a pulmonary problem, you always have to determine who is my patient, who is your patient, and who is our patient.
DR. MARK NOLAN HILL:
Why is it taking so long for us physicians to utilize people in your specialty?
DR. HOWARD HEIT:
Unfortunately, there are not a lot of people in my specialty.
DR. MARK NOLAN HILL:
That's true.
DR. HOWARD HEIT:
Because again we come back to the basic training that I had no training in pain or addiction during my years of internship, resident medical school, fellowship, etc. I had no training in the interface of pain and addiction.
DR. MARK NOLAN HILL:
In interrupting you sir, could you tell us a little bit about your personal story, which really personifies this discussion over methadone and pain management.
DR. HOWARD HEIT:
Well, my story is a little bit unusual. I am speaking to you and I am in my third life when I am speaking to you. My first life I was completely in football, played divisional football at the University of Pittsburgh and then I met my wife and she domesticated me and introduced me to the finer things in life. My second life was as a board certified gastroenterologist and hepatologist. My third life began in 1986, March 28, 8:15 at night while going to the NIH for liver journal club, a young fellow was speeding in the head-on in a car crash that gave me a very very rare muscle disorder called axial spasmodic torticollis that made me a chronic pain patient and put me in a wheelchair for 20 years.
DR. MARK NOLAN HILL:
Oh, my!
DR. HOWARD HEIT:
And being a chronic pain patient and going to see doctors and not sitting in my usual uncustomary chair, it became very apparent to me that my fellow physicians had little or no knowledge of pain management and I thought to myself that this was happening to me, some of the foolish things were said to me. If this was happening to me as the next jock, next football player at the Vision One, a physician, and a mayo, what was happening to the average personnel there who did not have my background and I decided to make that my passion and my life worth by retraining in pain and addiction medicine.
DR. MARK NOLAN HILL:
If you have just joined us, you are listening to the Clinicians Roundtable on ReachMD. I am your host, Dr. Mark Nolan Hill and our guest is Dr. Howard Heit, a nationally recognized chronic pain and addiction specialist practicing in Northern Virginia and an assistant clinical professor at the Georgetown University School of Medicine. We are discussing trends and considerations associated with the prescription of methadone.
DR. MARK NOLAN HILL:
Dr. Heit, you just told us that very personal story. Tell us the impact that it had on your fellow physicians when you decided to change specialties and go into pain and addiction management.
DR. HOWARD HEIT:
Well, the impact, Mark, that my fellow physicians had is initially you felt very very isolated. Initially, again, I was an assistant chief of GI at a big hospital, I was chief of the endoscopy ward, and all of a sudden, I couldn't go to rounds, I couldn't go to do many things that I did as far as patient care, and I had a couple years that were struggling of what I was going to do with my life until I decided that this is the field that I was going to go into because I had to make a decision secondary to my lack of mobility at that time, that it had to be an outpatient profession that I chose and I had to be a 100% outpatient because I didn't have the mobility to go inpatient and so I wont say that my fellow physicians were extremely helpful in this particular area.
DR. MARK NOLAN HILL:
Do you share this personal story with your fellow patients?
DR. HOWARD HEIT:
I have shared the story because I think its very very important that they understand that I know what they are going through on both sides of the desk and that helps me bond and increase my communication with my patients, that they understand that I know what it feels to be in chronic pain and how devastating it can be in your life.
DR. MARK NOLAN HILL:
Dr. Heit, if you would give a physician a report card, a grade as to how well we are doing in pain management in this day and time, how are we doing?
DR. HOWARD HEIT:
Gentlemen see at most.
DR. MARK NOLAN HILL:
What makes you say that?
DR. HOWARD HEIT:
Well, I live in a very sophisticated area outside of Washington DC and its very very difficult for someone to find someone to take care of their chronic pain problem and its almost impossible if the person has a background of addiction in their clinical history to find someone and so if this is happening in a very sophisticated area outside of Washington DC where I am one of the few if only doctors doing pain and addiction medicine, what's happening across the country in less sophisticated metropolitan areas or rural areas, I think this is a national disgrace in regard to the undertreatment of pain because its costing our country billions, that I said billions of dollars in loss protectivity in regards to the undertreatment or non-treatment of pain.
DR. MARK NOLAN HILL:
But our physicians frightened if they undertreat a patient for pain, they get in trouble and if the overtreat a patient for pain, they get in trouble, were between a rock and a hard place.
DR. HOWARD HEIT:
Well, I would say, the chances of you getting into trouble with undertreating pain is very small compared what physicians feel if they treat pain. When you say, its not all about the money, its all about the money.
DR. MARK NOLAN HILL:
What do you mean?
DR. HOWARD HEIT:
Well, lets face it. If you have a busy practice and an internist or a family practitioner and you have somebody with chronic pain and you know of the stories that are in the media and the methadone stories, then you hear about the death from methadone, you say, why do I need this aggravation, I only have 10-15 minutes to see the patient and I am not going to get reimbursed anything more by seeing this complex patient and so nobody is going to say anything if I don't treat that patient while I will perceive that I will get into trouble and put more aggravation on my life and my practice if I do treat the patient and I think that's wrong. I think this is a chronic disease, pain is a chronic disease, and there is just as much time to do this properly as it takes time to do chronic diseases appropriately such as chronic obstructive lung disease or diabetes to interact with the patient.
DR. MARK NOLAN HILL:
Let me ask you a question thinking about what happens to all of us as clinicians? Lets say, I am covering for Dr. Smith, another surgeon and I get a call on a Saturday evening from a patient of his that I don't know and they say, "oh, doctor, I am in great pain, I had an operation and I ran out or I lost my prescription or lost my pills or I am out of town and I need some Vicodins or something like that," and we are worried of course that perhaps this patient is manipulating me, how do you deal with that situation?
DR. HOWARD HEIT:
Well, I deal with the situation that's in my opioid agreement that my patient has enough medicine from appointment, appointment plus 3 days extra in case there is a delay in the appointment either by my schedule or his or her schedule or by the weather and I think that the particular practice has to have a meeting and bring up this particular situation that we are not going to prescribe certain pain medications after hours or on weekends and the patients will learn this very very quickly that these are the rules of this particular practice and therefore they will make sure before the weekend comes or before 5 o'clock that if they need the medicines, they call the doctor who has prescribed them originally the medicines, so the chart is available for that refill or not.
DR. MARK NOLAN HILL:
Do you think that may be interpreted by some patients as being a little hard land?
DR. HOWARD HEIT:
Well, again I say, this is my practice and that's why its called my practice. I get the rendered anyway that I want, just like any other business, its my practice and what I like doing that on protecting the valid pain patient, on protecting my staff, on protecting myself, and on protecting my community because we know that prescription drug misuse and especially opioids in a study by Substance Abuse Mental Health Services Administration (SAMSA) has shown that prescription drug misuse or addiction now exceeds marijuana as a national health problem. So if I presented to my patient, these are the rules of how my office works for the good of you, the good of my staff, the good of my family, and the good of my community, then that's the way it is and that's why I think its important for the pain doctor to know addiction medicine because there's a term called "my way or the highway or tough love."
DR. MARK NOLAN HILL:
Do you think that in our chronic pain patients that the use of methadone will be more prevalent than other medications?
DR. HOWARD HEIT:
I think so because unfortunately as we sit here now, our healthcare system is less than optimal in regards to its efficiency and this is a wonderful medicine as I said earlier, it's a very very cheap medicine if you used appropriately and like I said its enough for getting medicine, its used inappropriately and I think its going to have a bigger and bigger role as time goes on just because it's a very cost effective way to treat pain.
DR. MARK NOLAN HILL:
I want to thank our guest, Dr. Howard Heit. We have been discussing trends in considerations associated with the prescription of methadone. I am Dr. Mark Nolan Hill and you have been listening to the Clinicians Roundtable on ReachMD, The Channel For Medical Professionals. Be sure to visit our website at www.reachmd.com featuring on-demand podcast of our entire library and thank you for listening.
