Q&A with Dr. Doris K. Cope: Michael Jackson was just a symptom of a pain medicine problem
The American Society of Anesthesiologists wants to change the way people think about pain medicine, both to promote the idea that anesthesiologists are not just experts in the surgical suite and also to prevent addictions and deaths. The ASA's Life Line to Modern Medicine campaign comes at a time when pain medicine is under the media spotlight because of the apparent mishandling of painkillers and other drugs that resulted in Michael Jackson's death.
Dr. Doris K. Cope is a longtime member of the ASA Committee on Pain Medicine who is board-certified both in anesthesiology and pain medicine. A professor and vice chairwoman for pain medicine in the Department of Anesthesiology at the University of Pittsburgh Medical Center, Cope has published extensively about anesthesiology and pain care.
I reached her at her office in Pittsburgh. The interview has been edited for space and clarity.
Q: Why this campaign at this time?
A: First of all, Americans are living longer. They are living to advanced ages and are more active than in the past. The proportion of the population over 65 is the most rapidly growing segment of our population right now. These people have more leisure time, and they want to have more active lifestyles than in the past. The day of grandmothers sitting rocking on the porch and knitting is more of an archetype than a reality. The advances we have made in cancer, heart disease and other diseases means that people are living longer, often with illnesses. Rather than dying of an acute infection, their bodies are slowly wearing out. This means arthritis. This means pain.
Also, we have new technologies and new ways now to help people deal with their pain while avoiding drugs. At the same time, there is this growing demand in our society for instant cures and instant fixes. If someone can't sleep well, like Michael Jackson, he wants propofol. If someone had an unfortunate childhood, a pill or a drug or a drink or shopping or something can be used to elevate their mood temporarily. But those short-term solutions become less and less euphoric and more and more necessary. At some point, their brain chemistry resets itself so they are taking drugs just to feel normal, not to feel happy. Someone like Michael Jackson used more and more drugs just to try and feel normal. They need to know that pain medicine is not a quick fix. It's like every other aspect of medicine. Doctors need to consider the whole patient and find the best way to treat that person.
Q: How much did the Michael Jackson case play into the ASA's decision to make this public relations push?
A: This is something we have known as pain specialists for a long time. I am a trained, board-certified anesthesiologist, but my total specialty is pain and chronic pain. I don't give anesthetic in the OR. The general public would like to come see Dr. Cope and get a pill that will make everything perfect in their life. If I don't give them a pill, I am either too stupid or too mean to take care of them. Michael Jackson is a symptom of that attitude, of that want for instant gratification. "I want to feel good now and sleep now. I don't care what the cost is. I want what I want when I want it." We all know if we eat too much, we are going to have to pay the price in being overweight, and yet we still eat too much. I'm including myself. I have lost 50 pounds over the past five years. It's the same 5 pounds 10 times.
Q: It's not obvious to most people that they should see an anesthesiologist for pain care. What do anesthesiologists bring to the table?
A: Anesthesiologists have had pain as our main concern since it became a specialty in the 1800s. We know more about these drugs and more about these procedures than anyone else. You can't just give people shots and have them go away pain-free. You have to diagnose the pain and find out what kind of pain it is.
Q: What do you mean by that?
A: There's nerve pain, sympathetic pain, muscle pain, cancer pain. It's like an infection. You can't just say there's one infection. You have to know where it started and what type of infection it is. With pain, you have to know where the pain is. Also, we are used to being the hub of the wheel. We are the psychiatrists of the operating room. We have to balance the needs of the patients, the nurses, the surgeons, the schedulers, the administrators and keep everything calm and quiet. You never hear an anesthesiologist pitching a fit. Pain doctors do the same things, but mostly outside of the OR. I have patients with primary care doctors, spine surgeons and oncologists. I have to coordinate who is writing the prescriptions for the patient, who is doing the procedures, how the patient's needs are being addressed. We are used to being diplomats and mediators. I had a patient today on a blood thinner who also had arthritis back pain and needed a procedure. Because of that, the patient needed to be off the blood thinner. I had to coordinate with the primary care physician, the cardiologist and the spine surgeon.
Q: Are you making calls on behalf of the patient? Are you talking to people in halls? What exactly are you doing to coordinate?
A: I am doing whatever it takes to be the bridge between these silos. Sometimes I am making the call. Sometimes I am communicating through the patient. "Make sure you tell the doctor this."
Q: The ASA breaks pain medicine into acute, chronic and cancer pain. Tell me a little about the differences.
A: Acute pain is typically what you experience if you have an acute injury or motor vehicle accident. It's usually sudden and usually gets better. It's like putting out a fire. Chronic pain is like keeping the central heat going in your house. You have to maintain a steady level. You're not going to give the same pain medication to someone for 10 years that you would give them for 10 hours post-op. Chronic pain takes on a life of its own. Acute pain receptors are sodium and potassium. Chronic pain receptors are different. They actually have different chemical mechanisms that trigger the feeling of pain.
Q: And what about cancer pain. Isn't that a type of chronic pain?
A: Yes. Cancer is a different type of chronic pain. Cancer pain requires dramatic quick action. It's chronic pain in an acute setting.
Q: Tell me a little about the training that goes into becoming a pain medicine or pain management expert.
A: Pain management was the term that a lot of people used in the past, but we really need to be talking about pain medicine. You manage apartment buildings. You don't manage pain. And by using a term like management, it takes it out of the medical world. People say they are skilled in pain management, when they are not even physicians. People who are massage therapists or acupuncturists are not necessarily physicians. It doesn't mean that they can't do things that alleviate pain, but they don't have the same level of skills and depth of knowledge about pain that a true pain specialist will have.
Q: And what are the steps, specifically?
A: It requires an MD degree, first. You usually go through a fellowship, a year of specialized acute pain treatment. We have ACGME accredited fellowships for that purpose. Pain specialists should be board certified in pain medicine. The American Medical Association recognizes a one board certification in pain medicine.
Q: So there are other boards, but the AMA only acknowledges one. What are the other boards?
A: There are certainly some bogus boards. One is called "pain management," which, as I said, sounds similar but is not. The management board doesn't require the same degree of training or expertise. The true pain medicine board exam is administered by the American Board of Anesthesiology, but you can take it through the neurology board or psychiatry board. It is the same exam.
Q: A lot of people are probably getting their pain care through psychiatry, right?
A: Many physicians, not just psychiatrists, will treat pain. When it gets beyond what they are comfortable doing, they call in a pain specialist. We don't think it's reasonable that pain specialists write every pain medication prescription that anyone ever takes. If you have migraine headaches, it might be that your family practice doctor is very successful in managing them. We are there for the particularly difficult cases, the complex cases and the chronic cases.
Q: What do you think about what appears to be an increasing number of pain clinics or pain centers, doctors' offices that are trying to lure patients with the promise of pain cures?
A: Some are excellent and need to be there. Some are run by qualified, certified people doing a good job. And others are shopping center offices where a nurse practitioner has set up shop and knows just enough about pain to sound credible to someone who just needs help.
Q: If I'm a patient who needs help, how would I know the difference?
A: Ask for the qualifications of the person doing these procedures or prescribing the medication. Find out how well are they connected with the medical community. Do they partner with other doctors, or are they just an isolated office for quick stop drug shopping? If they aren't part of the larger community, that could be a bad sign. One Sunday afternoon I was coming home from church and outside an old abandoned gas station, there was a line of people who looked pathetic, with crutches and braces, people who appeared to be in pain. I asked around and found out this was a pain doctor who had just set up this clinic on the fly to write prescriptions for Oxycontin. So, some of those patients probably needed the drugs for their pain and some of them needed a fix. Before long, he disappeared. He's probably running from the law.
Next week: Cope talks about whether pain specialists have played a role in creating the new wave of painkiller addicts.