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be ineffective. A vocal contingent opposes prescribing opioids to patients with chronic pain, inexplicably unless the patients have cancer. I wish they would first listen to the stories of people who are crying for help and who have no clinically viable alternatives. It is too infrequent that policymakers, regulators, members of the press and government officials ever express concern for these people. That saddens me. PMN: Critics have called this discussion of physician prosecution a “false narrative.” What is your response to that? Dr. Webster: If you mean that it is false that there may be overreach by some regulators and prosecutors, I would say the facts state otherwise. Look at the case of Daniel Baldi, a doctor of osteopathic medicine and a pain physician in Des Moines, Iowa. He was recently charged with nine counts of involuntary manslaughter in patients who died of overdoses, complicated by multiple factors that included worsening medical conditions, medications prescribed by others and the co-ingestion of illicit drugs. In one case, Dr. Baldi had not seen the patient for months leading up to the death; in another, Dr. Baldi had only seen the patient once. However, the common denominator was that each patient had been prescribed opioids. The deaths were tragic, but the charges were unconscionable. The judge dismissed two counts, and the jury acquitted him of the rest. Regardless, Dr. Baldi’s career and finances are ruined, although it was clear in court he had practiced in good faith and did all he could to help his patients. Other physicians throughout the country are being forced into plea bargains because they can’t afford a defense. Aside from prosecution, regulators target “high prescribers” for investigation without sufficient context to evaluate the type of practice they run or the patients they treat. Actions like these clearly create a chilling effect. There is no false narrative.
the implication is that there is something fishy and the perception of wrongdoing takes root. As a physician who has treated people in pain all my professional life, I always grieved for patients we treated but died. The fact is that some Lynn Webster, MD patients at our clinic died in spite of their treatment, but not because of it. This underscores the complexity and, sadly, inability of society to address the crisis of chronic pain. As for CNN, I do not take issue with them producing a story for national consumption, but how they did it. The processes by which they collect, analyze, verify and double-checkk the facts call into question the network’s professionalism and journalistic integrity. I’ve made some of the inaccuracies in their story known to them and they’ve acknowledged this in correspondence with me. I did not participate in an interview with CNN, and I had no obligation to participate. However, that does not relieve CNN of its obligation as journalists to ensure their stories are free of error, bias and guesswork. This they did not do. PMN: You have long said opioids need to be replaced as viable treatments for pain. Where should we go from here as a society to make that happen?
Dr. Webster: This is true. It would be morally reprehensible to abandon our societal obligation to treat mankind’s primal enemy: pain. There is controversy now about how many people in America actually suffer from chronic pain. Regardless, pain is the No. 1 reason people visit a physician. It will take time, but it is imperative to find safer and more effective alternatives to opioids. Not only because of the politics surrounding opioids but because, as medications, opioids are not effective enough and cause too much harm and grief. As a country, we should invest heavily in better therapies because of the prevalence and financial cost to society of untreated pain and addicPMN: You were the subject of a CNN story by tions. We need a short-term strategy and a long-term Dr. Sanjay Gupta last year. The story centered strategy. In the near term, we must increase access around the deaths of two former patients from your to effective alternative therapies, which exist but are clinic. Do you feel vindicated given that the U.S. too seldom covered by insurers. Every time a reguAttorney declined the case? lator complains about the harm from opioids, he or she should also offer to support making available Dr. Webster: Vindication implies that I was effective alternatives. We need guaranteed minimum accused of wrongdoing. I was never accused of any insurance coverage for pain therapies. We also need wrongdoing, but when the DEA makes an inquiry, better education about the risks and benefits of all
PNB
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set and is technically challenging,” said Dr. Sinha, who added that risk for infection is also a consideration with PNBs and their associated use of catheters, and that use of PNBs demands greater manpower resources. The use of local infiltration anesthesia can produce sufficient pain control for patients undergoing TKA. Dr. Sinha referred
to one study ((Acta Anaesthesiol Scand 2008;52:1331-1335) involving 12 patients who underwent bilateral TKA. Ropivacaine was administered in one knee and saline in the other, so patients served as their own controls, and patients received multimodal medications postoperatively. “They [researchers] found pain control was superior in the knee that had local anesthesia as opposed to placebo,” said Dr. Sinha.
Colleagues Comment on End Of Webster Investigation
“R
egarding the investigation into the Lifetree Pain Clinic, Dr. Webster was forthcoming in discussions with the American Academy of Pain Medicine board of directors. And although this investigation undoubtedly caused him real concern and embarrassment, he upheld his responsibilities as the Academy’s president with great conviction and professionalism. I was proud to have worked closely with him during that time, and I am very glad that the matter has been put to rest.” —Phillip A. Saigh Jr., executive director, American Academy of Pain Medicine
“W
ith this behind him, I am pleased that Dr. Webster can fully focus on his contributions to advancing research and care for people with pain. Given the significant challenges today to effectively address the challenges of these complex patients, his efforts and attention are needed without distraction.” —Steven D. Passik, PhD, pain psychologist
treatment options, not just opioids. In the long term, we need Congress to create incentives for industry to develop safer and more effective therapies. We can do better if we have the will. PMN: What do you look forward to accomplishing going forward? Dr. Webster: My mission during the four years of the investigation was the same as it has always been: to help people living with pain and to prevent opioid abuse and overdose deaths. Going forward, I plan to adhere to that core mission. I agree with the Institute of Medicine that we need a cultural transformation. Access to appropriate and safe pain treatment should be viewed as a human right—a civil liberty. I am working on a television documentary profiling the lives of people in pain, which, tentatively, is planned for national broadcast in fall 2015. I am also working on a book. It is not a book about how to treat pain or the politics of pain. It is an experiential journey with some of the people I have treated. Their stories, the documentary and efforts to promote the National Pain Strategy through the National Institutes of Health is where I will invest much of my energy for the next couple of years. Then I will see where we are. I hope it’s a better place. ■
Dr. Sinha also pointed to a metaanalysis that looked at local infiltration anesthesia directly into the knee ((J Bone Joint Surg Br 2012;94:1154-1159). The authors concluded that local infiltration produced a reduction in postoperative pain. The emergence of agents like liposomal bupivacaine may assist in prolonging postoperative analgesia and potentially decreasing use of opioids post-discharge, according to Dr. Sinha.
One of the potential risks associated with PNB is nerve damage, said Dr. Sinha. “Anytime you do a nerve block, there is a risk for nerve injury.” However, a review of 32 studies (Anesth Analgg 2007;104:965-974) found the rate of neuropathy after PNB to be 3%, but investigators found the occurrence of permanent postPNB neuropathy to be very rare. —Louise Gagnon