WhiteCoat

Ten Years In the Greybar Motel

Dr. Phil Astin pleaded guilty to a 175 count federal indictment against him alleging that he indiscriminately prescribed multiple pain medications and other narcotics to known addicts for years. According to the indictment, “at least two of Astin’s patients died because of his lax oversight of what medicines they were taking.”

One of Dr. Astin’s patients was Chris Benoit, the professional wrestler who murdered his wife and child, then committed suicide in 2007.

Today, Dr. Astin was sentenced to 10 years in prison.

The federal investigation into Dr. Astin’s practice discovered that he often wrote prescriptions without conducting physical exams, gave multiple simultaneous prescriptions for strong pain medications, and prescribed combinations of multiple pain medications that would have an additive effect such as Percocet plus Oxycontin plus Vicodin. Many of the prescriptions were deemed not to have been written for “legitimate medical purposes.”

Most doctors would agree that practices such as those above are inappropriate.

But there are exceptions. And sometimes it is difficult to draw the line between what is “legitimate” and what is not “legitimate” for pain management.

In the hearing on Dr. Astin’s sentencing, U.S. Attorney David E. Nahmias made the statement that Dr. Astin engaged in “illegal drug dealing.” Then there was Assistant U.S. Attorney John Horn, who, according to this article, reportedly made the idiotic statement that “Medical doctors know that after a period of time, if the prescriptions are not working, you get them off.”

“Sorry, ma’am, I know you have advanced metastatic bone cancer and your progressive pain is not being controlled by your Duragesic patches and Percocets, but because Assistant US Attorney John Horn says so, I have to “get you off” all your medications so you can die in agony. Wouldn’t want to go to prison, you know.”

The whole case brings up a difficult ethical issue. On one hand, some bad apples are prescribing narcotics for fun and profit. On the other hand, some patients really need large doses of pain medications to control their pain.

If the facts of the case are as stated in the news articles, Dr. Astin deserved a harsh penalty. I can’t comment on the whole prison thing other than to mention that if you think doctors practice defensive medicine to avoid lawsuits, watch and see what happens if they think there’s a possibility they could go to prison for prescribing pain meds.

I continue to believe that we need to do a better job policing physicians that prescribe medications in the manner that Dr. Astin did. Part of the problem lies in oversight. How is it that the feds have to wait for someone to die before they investigate a physician that is prescribing medications in this manner? If federal investigators can get the prescription records years after the fact, they can get them shortly after the prescriptions are written and/or filled. The DEA and/or state licensing boards should be more proactive in this regard if there are concerns.

On the other hand, when everyone hears some ill-informed statement like that made by John Horn, what effect do you think will have on doctors being willing to prescribe pain medications for patients who are in legitimate pain?

4 Responses to “Ten Years In the Greybar Motel”

  1. First the government mandates that pain be treated and objectify it by the “pain scale” the biggest crock to come down the pike. Now prescription drug abuse is rampant which is a no brainer..gee could there possibly be a connection. Now there is legislation called the pain control act of 2009 which wants to address those with UNTREATED or POORLY MANAGED pain. Damned if you do, damned if you don’t. Is it any surprise that another federal mandate is taken advantage of by unscrupulous people, both docs and patients. People who truly need pain management suffer the stigma of being drug seekers while those working the system make out like a bandit. It’s a total catch 22.

  2. Nurse K says:

    I once wrote up Bloody Gloves for calling in Vikies over the phone for patients he’d seen in the ER x 1 in the past. Patients call, he calls them in what they would like for their pain, never directing them to their primary care doc.

    “It’s not your license, K, what do you care?” is the refrain from my fellow nursing staff. Everyone has been brainwashed into thinking narcotics are the only treatment for pain and that anyone who wants them should get them, and it pisses me off to no end.

  3. tyro says:

    I get what you’re saying, Nurse K, but what am I supposed to do if everyone teaching me is saying treat pain, treat pain, government included?

    Most of the chronic pain patients that come in have some real pain kernel that started their whole dysfunction and we turned them into addicts because they were complaining of pain we were supposed to treat via the ‘5th vital sign’ (actually the sixth, I think pulse ox is kinda important).

    A lot of nurses get mad, though, when I give narcotics to people–so what am I supposed to do? Let them withdraw in my ED? I suppose that’s one option. Send them to psych? Can’t if they’re here voluntarily. Give them NSAIDs? Possible but they often don’t work and if they’re hypertensive or have gastric disease, not good either. We’re a bit stuck.

  4. I am one of the dreaded chronic pain patients. My pain is horribly undertreated, but this is because of me overpolicing *myself*, as well as overpolicing my doctors.

    I have never gone to an ED with a primary complaint of pain. That said, when I have had to go, pain has been an issue. In all the cases which led to hospitalization, I asked to be given only what I am prescribed to take at home, and hospital staff are happy to oblige. While in the ED, I refuse pain meds, as I truly don’t want my home regimen screwed up.

    But what I wanted to say — anyone being treated for chronic pain has insight into how pain works and how many different modalities beyond narcotics can provide relief. Everything from heat/cold to antidepressants and anticonvulsants. Deep breathing exercises, mindful meditation, drugs like NSAIDS (I had the greatest relief ever from bone pain when a nurse had me try Toradol… It broke my heart when I was told I couldn’t continue to take it… Due to some mamby-pamby reason like a plummeting Hgb).

    I do not envy you health care professionals as you face drug-seekers — you have my sympathy. But I do get angry when I feel lumped in with said drug-seekers, because I would likely only show up in an ED if drugs had *ceased* to work — my arsenal at home is as strong as I wish to go with medication for pain. In that eventuality, I would be worried about an underlying acute disease “process” kicking in… but might be too quickly pigeon-holed to get the attention I might need.

    So I hope you are able to maintain your cool and work the problems before you, as they are singular people, not representatives of all that is wrong with the world.

    There are days I long to take as much medication as I am told to take — but have never fallen in love with that gorked-out feeling, or daytime television. I know that it is a slippery slope once I start to seek real relief — so I undermedicate and try to cope. I am not coping well at the moment and for the first time in three years am considering a change in the narcotic part of my pain meds.

    You probably don’t believe it, and it really doesn’t matter, but were you doctors and nurses to experience what I experience daily? Well, I don’t think you could manage. I don’t think you can even *conceive* of this level of pain, sustained over extensive time. So why should I expect health care workers to really try to “treat” or control it, were I to present to you as a patient? It scares the bejesus out of me to ponder a visit to the ED because of uncontrolled pain.

    It’s bad enough that as an inpatient recently, an ICU nurse responded with one of my regularly scheduled methadone as an answer to my complaint of acute pain. I explained the lengthy half-life, I explained the immediacy of my pain (post-op) and she said, “Well, I will just put down that you refused your pain medication.”

    She said it with such glee.

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