August 17, 2017

A doctor's murder leads to soul-searching about the opioid crisis

Daily Briefing

    Todd Graham was murdered after refusing to prescribe a patient opioids. Now, his community is trying to figure out how to handle patients who demand opioids, and how to protect providers, Megan Thielking writes for STAT News

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    The murder of Todd Graham

    On July 26, Todd Graham, a doctor at South Bend Orthopaedics in Mishawaka, Indiana, saw a new patient who complained of chronic pain and requested opioids. Graham told her that opioids weren't the right course of treatment and maintained his position even after the patient's husband insisted on the pills and, according to Thielking, "grew irate."

    Graham ultimately pulled out his phone to record the argument until the couple departed without the prescription, but he did not call the police.  

    Two hours later, the patient's husband, Michael Jarvis, returned to the orthopedics office, where he confronted Graham in the parking lot and shouted at him. Jarvis then pulled out a semiautomatic weapon and shot Graham.

    Mishawaka is a Midwestern town of around 46,000 people, and like many towns in the area, it has been hit hard by the opioid crisis. In St. Joseph County, which includes Mishawaka, 59 people died of overdoses last year, and 58 died the year before. According to Thielking, that is more than the number of homicides and fatal car accidents combined in the county.

    Graham's murder has "reverberated" through the town, particularly the providers, many of whom knew Graham and also have dealt with unhappy patients seeking an opioid prescription. In those cases, the providers "say they would've done the same thing. Many of them have," Thielking writes. "Now, they're not so sure."

    How providers are responding to patients who demand opioids

    Providers who are confronted with patients seeking "the quick fix of an opioid prescription" may find themselves in a difficult position: On one hand, they do not want to write an unnecessary prescription or call the police on a patient. On the other, some patients may become angry or even violent when denied the drugs.

    Brandon Zabukovic, a local family medicine provider who also sees patients who are in treatment for opioid use disorder, has dealt with the dangers of refusing opioid prescriptions in the past. "I have had knives pulled on me over narcotic prescriptions," he said.

    In response, Zabukovic decided to no longer prescribe long-term opioids to anyone but cancer patients, referring all other patients to pain specialists.

    American Academy of Pain Medicine President Steven Stanos recommended that providers have a plan in place in their office for how to handle a belligerent patient, such as having a social worker or psychologist on call to help take care of the patients.             

    Providers engage with law enforcement on new approaches

    Within days of Graham's murder, St. Joseph County Prosecutor Ken Cotter says he received around 20 calls from doctors who were concerned about their safety, as well as the safety of their staff and patients. As a result, Cotter is bringing both providers and law enforcement to the same table to rethink how the county approaches opioid misuse.

    Cotter has worked for years to keep individuals who misuse drugs out of jail and in treatment, but up until now he has opposed needle-exchange programs, drug safe zones, and the use buprenorphine, a medication that helps curb cravings to wean people addicted to opioids off the drugs. Cotter said he viewed the medication, which itself is an addictive substance, as swapping one opioid for another one.  

    Now, though, Cotter is reconsidering his stance. He said that discussions with providers on buprenorphine have prompted him "to reconsider that there might be a place for that."

    A shortage of resources

    Though talks between local law enforcement and providers in St. Joseph County are still in the early stages, there is one common problem everyone agrees on: local resources are too scarce to deal with the opioid epidemic.

    The closest medical detox facility to Mishawaka is 35 miles away. The closest inpatient addiction center is over 80 miles away. Add in the fact that every homeless shelter in the town bars people who are still misusing drugs from coming in, and the town isn't left with many options.

    "Right now the best place for somebody to dry out is in jail. It's not the best place, by far, but it's the best place we have," said Cotter.

    For now, Cotter recommended providers contact the police if they feel uncomfortable. "The last thing we want doctors to worry about while prescribing is safety," Cotter said (Thielking, STAT News, 8/8).

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