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Patient-on-Provider Violence in the Pain Clinic

DENVER — Pain clinicians were likely to encounter violent patients, including assaults and threats revolving around opioid treatment, a review of literature showed here.

In a special session at the 2019 American Academy of Pain Medicine (AAPM) meeting, David Fishbain, MD, of the University of Miami in Florida, and W. Michael Hooten, MD, of the Mayo Clinic in Rochester, Minnesota, highlighted research about pain patients, health care providers, and potential violence.

The impetus for the session was the 2016 murder of northern Indiana physician Todd Graham, MD, by the husband of a chronic pain patient, Fishbain said.

Threats against pain clinicians are common, Fishbain added, citing survey data published in Pain Medicine that showed 51.5% of chronic pain care providers have received threats from patients, with 7.1% of those threats involving guns. The most common context for violence was opioid management at 89.9%.

“This is a hidden, but well-known, problem that no one is really addressing,” said David Kim, MD, of the Henry Ford Health System in Detroit, who co-authored the Pain Medicine report.

“It isn’t surprising that medicine has become dangerous since our society has become more violent,” Kim, who was not part of the AAPM presentation, told MedPage Today. “And it isn’t surprising that the biggest percentage of problems with violence in pain medicine involved opioids. What is disturbing was that some physicians were desperate enough to carry handguns for self-protection.”

Perceiving what may trigger violence is key, Fishbain told the audience. Research has shown that, compared with community controls, chronic pain patients report significantly higher scores in violent ideation. “This ideation was associated with worker’s compensation status and personal injury status; these are two predictors of potential violent ideation in chronic pain patients,” he pointed out.

Chronic pain patients also are four times more likely to express homicidal ideation toward their physician, which is linked to several factors including doctor dissatisfaction. Homicidal ideation in chronic pain patients also is tied to suicidal ideation: “When somebody decides they are going to kill a physician, that’s associated with the idea that they’re going to kill themselves, too,” Fishbain observed.

Chronic pain patients have shown a greater prevalence toward chronic anger, with the highest anger targets being themselves (74.2%) and their health care provider (62.4%), Fishbain added.

Treatment goals that interfere with a patient’s agenda can ramp up hostilities even more. “Physicians need to understand the agenda of the patient,” Fishbain emphasized. “They need to understand whether a patient is coerced into treatment; this is very, very important. And they need to understand the impact of the proposed treatment plan, including the physician-patient alliance and any predisposition to violence that may be worsened by drug abuse. Understanding these issues can potentially prevent violent behavior.”

Little research about protecting pain clinic employees from violent patients has been conducted, but several strategies have been effective in other areas of health care, Hooten told the audience. These include:

  • Assessing treatment rooms, removing potential weapons, and using safety glass in mirrors and windows
  • Ensuring all employees are aware of angry, hostile phone calls from patients
  • Informing security before a potentially violent patient’s appointment so they are ready to respond
  • Establishing aggression management teams to demonstrate a show of force
  • Developing communication and de-escalation strategies
  • Learning evasive self-defense and breakaway skills

If a violent incident does occur, debriefing can be important but may not affect future violence rates, Hooten noted: a prospective study of workers in 47 health care settings showed debriefing did nothing to decrease violence a year later. “Simply talking about what happened is not good enough,” he said. “It will increase awareness of potential problems but does nothing to mitigate the risk, unless post-incident reporting is linked to some type of action.”

The Joint Commission also has issued recommendations to help health care organizations prevent violent encounters, which were not discussed at the meeting.

Neither Fishbain nor Hooten had anything to disclose.