The late Todd Graham, MD, in South Bend, Indiana, was primarily a physiatrist, and devoted only a small portion of his practice to pain management. According to his best friend, Dr Graham was trying to phase out of pain management completely because of how the opioid abuse epidemic had changed that field over the years.
“Patients have become more difficult,” said A. J. Mencias, MD,”A lot of them don’t react so well when you deny them opioid painkillers.”
Sometimes relatives of pain patients who hear the word ‘no’ don’t react so well either, which happened to Dr Graham, a popular 56-year-old physician. He was shot to death on July 26 by the husband of a patient whose request for opioid painkillers he denied earlier that day. The patient’s husband, Michael Jarvis, then took his own life.
Dr Graham’s murder highlights the risk for physical violence faced by pain-management physicians, particularly as they and others come under increasing pressure to avoid prescribing opioids for chronic pain. The extent of that risk is a matter of study and conjecture. In a survey of members of the American Society of Interventional Pain Physicians (ASIPP) published in Pain Medicine in 2015, 52% said patients had threatened them, usually in the context of opioid medications, and 7% of the threats involved a gun. Sixty-five percent of ASIPP members have had to call security. Almost 3% reported being injured by a patient. And 8% said they carry a gun for protection.
Whether pain-management physicians say the ASIPP survey underestimates or overestimates the problem of belligerent and sometimes violent patients, the specialty nevertheless has its guard up, training clinicians on how to de-escalate angry confrontations and developing strategies to avoid them in the first place. The risk, in short, is real, said Edward Michna, MD, who serves on the board of directors of the American Pain Society (APS).
Tracked Down in the Parking Lot
At the time of his death, Dr Graham practiced at South Bend Orthopaedics, where he was a partner. He took a multimodal approach toward pain management, relying on everything from physical therapy to antidepressants, said Dr Mencias. “He believed in opioids for short-term therapy.”
Dr Graham, he said, had an excellent bedside manner, and patients’ reviews posted on the South Bend Orthopaedics website seem to bear that out. “Dr Graham…has always been very good at explaining my problems, answering my questions and explaining the treatments,” one patient wrote. “This is done with a pleasant, friendly demeanor and interest.” His patient satisfaction score was 4.3 out of 5. A few patients commented that Dr Graham seemed in a rush, although others said he took his time.
Outside of medicine, Dr Graham lived a full life. He and his wife Julie raised money for charities like a local center for people with intellectual and developmental disabilities, and he consulted with the University of Notre Dame’s athletic department on a volunteer basis. He skied. He played golf. He vacationed in Switzerland, southern France, and St Barthélemy Island in the Caribbean.
On July 26, Dr Graham had an appointment with the wife of 48-year-old Michael Jarvis, who accompanied her. Jarvis also was in chronic pain, and unemployed, according to St Joseph County (Indiana) Prosecuting Attorney Ken Cotter.
It wasn’t the couple’s first visit with Dr Graham. They had been in his office about a month before, with the wife seeking relief for chronic pain, Cotter told Medscape Medical News.
Dr Graham declined to prescribe opioid painkillers at that time, sparking a “strong disagreement” with Michael Jarvis, said Cotter. “He didn’t like the answers.”
The same scene played out on July 26. Dr Graham turned down the wife’s request for opioid painkillers, explaining that they weren’t appropriate for her chronic pain. “She understood, and didn’t want them either,” Cotter said about the conclusion of the second visit. “But [the husband] was insistent.”
The couple left, only for the husband to return to the office 2 hours later with a semiautomatic handgun. He intercepted Dr Graham as he was driving to an adjacent rehabilitation center and exchanged words with him. Jarvis followed Dr Graham and shot him twice in the head in a parking lot after the physician stepped out of his vehicle. Jarvis then drove to a friend’s house, where he committed suicide.
According to Cotter, there’s no evidence to suggest that Jarvis’ wife was involved in her husband’s murderous plan, or knew about it. “She’s suffering, too,” he said in a news conference shortly after the shooting.
“I Know Where You Live”
By all accounts, when a physician denies a request for opioid painkillers, hostile responses usually come from the patient, not a relative. Either way, the responses can be unnerving.
“Anybody who practices pain medicine has been threatened,” said Dr Michna, also an anesthesiologist and pain specialist at Brigham and Women’s Hospital in Boston, Massachusetts. “I’ve received notes saying, ‘I know where you live and that you have children.’ ”
Sometimes ire is sparked when a physician ends someone’s opioid therapy after discovering that the patient is taking illicit drugs as well. Another potentially combustible situation arises when a long-time prescriber of opioid painkillers retires, and a younger replacement tries to wean patients off the drugs. The risk for belligerent behavior, threats, and violence reflects the demographics of patients in pain, according to Dr Michna and others.
“Close to 70% of pain patients have psychological comorbidities, like addictive behavior,” he said. “Many have been in prison. They’re desperate.”
To Dr Michna, the ASIPP finding that 52% of pain-management physicians have been threatened seems low. In contrast, Joanna Katzman, MD, MSPH, president of the Academy of Integrative Pain Management (AIPM), thinks the figure is too high, especially in light of her own experience. Dr Katzman directs the University of New Mexico Pain Center in Albuquerque.
“We have no violence whatsoever,” said Dr Katzman, a professor of neurology at the University of New Mexico School of Medicine, in an interview with Medscape Medical News. “Verbal threats are very rare.”
She credits the peaceful atmosphere to patients knowing that her pain center does not prescribe opioids on the first visit, and that these drugs are far down on the list of possible treatments, which are interdisciplinary in nature. “If all this is laid out from the beginning, there are not unmet expectations,” Dr Katzman said.
Dr Michna at the APS agrees with that approach, saying that it has lowered the level of conflict and anger at his hospital. “Be upfront and mitigate false expectations,” he said.
Just Don’t Take Away Something
Another key to averting blowups over opioids is caring communication with patients, said Steve Stanos, DO, president of the American Academy of Pain Medicine.
For one thing, busy physicians need to stop looking at the clock and take time to explain why a patient is not a candidate for opioid therapy, Dr Stanos told Medscape Medical News. But the length of the conversation is not enough.
“You need to build rapport with patients, and win their trust,” said Dr Stanos, medical director of pain services at the Swedish Health System in Seattle, Washington. “When you don’t prescribe them opioid painkillers, you want to be seen as someone who’s looking out for their best interests instead of taking something away from them.”
What’s valuable with pain patients is motivational interviewing, in which the physician helps the patient in a nonconfrontational way to examine self-defeating behaviors and find the inner motivation to change them. “You want patients to manage themselves,” said Dr Stanos.
A pain-management physician can do all the right things, however, and still have a patient raise his or her voice, face reddening, hands waving. A bit of venting is tolerable, but at some point, a clinician may need to defuse the situation by bringing another person — a behavioral health expert, say — into the discussion, said Dr Stanos. Sometimes Dr Stanos will leave the room momentarily to let the patient decompress, and mull over what he’s said. And sometimes he announces that he will end the interview in so many minutes, and offer to make a follow-up appointment.
Of course, it may boil down to calling security, or the police. Threats of physical violence can’t be tolerated, said the AIPM’s Dr Katzman. Even at the University of New Mexico Pain Center, where threats are rare, staff get periodic training on how to handle a volatile patient. Krishna Chari, PsyD, a clinical psychologist at the center who has coached colleagues on emergency responses, said that a physician can simply tell the patient, “I don’t feel safe” and leave the room.
Packed Funeral Service
South Bend Orthopaedics closed its doors on July 26 shortly after Dr Graham’s murder, and stayed closed the next day. The group practice shut down again on July 31, the day of Dr Graham’s funeral.
Hundreds of mourners, including many patients, filled St Pius X Catholic Church in Granger, Indiana. Dr Mencias recalled how Dr Graham and his electric personality “lit up a room like the sky on the Fourth of July.” Travis Graham, MD, one of Dr Graham’s three adult children and an anesthesiology resident, said in a statement that he had planned to join his father as a physician in South Bend. “I hope I can be the kind of doctor he can be proud of,” the son said.
Dr Mencias said resuming work at the orthopedics practice has been surreal.
“All of my partners and I are nervous,” he said. “You hope that Dr Graham’s murder is a once-in-a-lifetime incident.”
Even so, just a few days after the shooting, a local emergency-department physician was threatened by a patient after he turned down a request for opioid pain medicine, according to Dr Mencias. This time around, no harm came to the physician, and the patient was arrested.