By Dominique Perkins
Growing up, Patrick Hogan, DO, used to visit his mother at work. She was an oncology nurse, and she brought him into the hospital unit to meet her coworkers. To a young boy, the bustling atmosphere and colorful uniforms had an instant appeal, and an interest in the healthcare field was born.
Naturally, this interest matured as did Hogan. As he progressed in his education, he found a lasting love of science. This, combined with the fond colorful memories of visiting his mother’s hospital fed his interest, while many outstanding teachers and mentors supported, encouraged, and fed his interest.
After graduating from Concordia College in Moorhead, MN, Hogan attended medical school at Midwestern University/AZ College of Osteopathic Medicine, here in Glendale, Arizona.
Our beautiful desert state took hold of Hogan immediately.
“During medical school, I absolutely fell in love with Arizona. Arizona exposed me to different cultures and a diverse population that I hadn’t experienced while growing up in the Midwest, he said.”
After graduating from Midwestern, he moved to Cleveland, Ohio to complete a residency in anesthesiology, and a fellowship in pain medicine at the Cleveland Clinic. But the West had won his heart.
“When I moved away to Cleveland to complete my training I thought about moving back to Arizona almost every day,” he said.
Once his training was complete, Hogan gladly accepted a position in Glendale and has been here for the past 8 years.
Two years ago Hogan and a partner, Tristan Pico, MD, founded their own practice, AZ Pain Doctors. Hogan currently serves as the CEO.
“We are proud that our practice has great patient success by using a multi-disciplinary “team” approach to managing acute and chronic pain,” he said of his group. This multipronged approach includes chiropractic care, acupuncture, interventional pain management procedures, stem cell injections, and medication management. Hogan has great confidence in the team they have put together and said that each of their physicians graduated from ACGME-approved fellowship and residency programs, and are Board-certified or Board-eligible in anesthesiology and pain medicine.
In light of today’s opioid crisis, this is a growing necessity. Our country is currently facing a prescription crisis, and blame is cast all around. According to the Morbidity and Mortality Weekly Report (2016;65), drug overdose is the leading cause of accidental death in the United States. In 2015, 52,404 instances were reported. While some of these are attributed to other drugs, opioid addiction leads the epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.
Facing down the issue
Managing this crisis, and coming up with solutions for regulation and oversight, are hot-button issues on the minds of governments, group and hospital leadership, and many physicians.
As a pain specialist, of course, this issue is very near and dear to Hogan’s practice, and he is taking an active part in facing down the issue. Hogan is currently the CEO of the Arizona Society of Interventional Pain Physicians (AZSIPP), an organization that is dedicated to preserving patient’s access to high-quality and effective pain management care.
“Our physicians believe that patients have a right to receive safe and effective pain management care,” Hogan said.
Hogan also serves on the Legislative Affairs Committee of the Arizona Osteopathic Medical Association, a position he says intertwines with his duties and goals at AZSIPP quite frequently, since both organizations are dedicated to preserving quality medical care.
“Currently, AZSIPP members are involved with scope of practice expansion issues and advocating for patients for improved access to interventional pain management,” Hogan said.
Organization members recently traveled across Arizona in coordination with medical associations and medical boards to educate providers about the opioid crisis. Others traveled to Washington, D.C., to meet with legislatures to encourage ongoing funding of the Controlled Substances Prescription Monitoring Programs (CSPMP).
Hogan described the CSPMP database as an integral part of modern daily practice.
“Reviewing it prior to opioid prescribing is already our policy at AZ Pain Doctors,” he said.
Beginning October 1st, all Arizona physicians may be required to check the database before prescribing.
“Unfortunately, the opioid crisis is a very serious problem,” Hogan said. “The research I have read seems to indicate that States which utilize databases, like CSPMP, have seen reductions in opioid abuse.”
While Hogan said that his overall experience with the database has been quite positive, he recognized that as a new requirement it may come with its own headaches or unintended consequences. Because of this, he feels it is important that a mechanism is implemented to gather physician feedback on the system so that adjustments can be made with a clear vision of the facts.
In addition to the growing numbers of addictions and fatalities surrounding opioid use, an increasing number of physicians have come under scrutiny, and face possible disciplinary actions for overprescribing opioids. Primary care physicians and others who do not specialize in pain management make up many of these cases.
Hogan advises considering non-opioid treatments before any prescription.
“If we can reduce “first-time” opioid exposure to patients we will reduce the rates of addiction and abuse,” he said.
When opioids are deemed to be the best course of action, Hogan advises short-term prescription treatments, while facilitating referrals to appropriate specialists. Of course, specialist referrals can be more difficult in some areas of the state, and in those cases, Hogan said it is important to follow the Medical Board guidelines for opioid prescribing.
“On those occasions where it becomes necessary to prescribe opiate medications, consideration should be given towards using abuse-deterrent opiates and providing naloxone antidotes for higher-risk patients,” he said. “The Medical Board guidelines are an excellent resource for other best practices in chronic opioid therapy such as urine drug testing, opioid agreements, etc.”
Governor Doug Ducey recently implemented an order limiting new opioid prescriptions to 7 days for patients who are a part of the Arizona Health Care Cost Containment System (AHCCCS) or otherwise insured through a state employment health plan.
As a measure to reduce first-time opioid exposures (and thereby reduce addiction and/or abuse) Hogan said the executive order has the potential to achieve positive results. Other avenues are being explored to curb the epidemic, he said, and much will come down to the public’s willingness to invest necessary funds into a solution.
“I am very impressed with the level of commitment Governor Ducey and our legislators have shown in trying to curb the opioid crisis in Arizona,” he said. “If our community is willing to make some short-term sacrifices, we can reduce the high costs we are experiencing due to opioid abuse long term.”
When approaching pain management in his own practice, Hogan takes a few steps to explore alternates to opioids with his patients.
The first step, naturally, is to ensure an accurate diagnosis through objective data, thorough patient history, and physical examination.
“Frequently, I recommend conservative measures such as chiropractic care, non-opioid medications, and physical therapy,” Hogan said. “If those modalities are not successful then appropriate interventional pain procedures are often available as options, as well as opioid medications.”
While much is said regarding the detrimental effects of opioid use, Hogan cautioned not to ignore the realities of the flip side.
“It is important to note that opiates may play a positive role in patient health, which is why they are prescribed,” he said. “Many patients who are prescribed opiates experience a significant reduction in pain and improvement in their quality of life.”
A hot topic in the realm of alternative treatments is the use of marijuana for medical benefit. However, Hogan expressed his opinion that there is not sufficient evidence, currently, to indicate significant pain reduction in marijuana use.
“I need to see more objective data, consistent dosing formulations, medication-interaction studies, and FDA approval,” he said. “Once those steps are achieved, I would feel comfortable that the benefits of using marijuana for pain management would outweigh the risks.”
A question of scope
The Arizona legislature and medical boards have faced many questions regarding scope of practice in the last few years. There has been a fair amount of talk about Certified Registered Nurse Anesthetists (CRNA) lobbying for expanded practice, including pain management.
Hogan described a predominately online nursing fellowship he has seen recently rolled out in Texas, which advertises teaching nurses how to perform x-ray guided spinal injections, as well as other procedures, and to diagnose and treat patients who suffer from chronic pain.
Hogan said that he, as well as the AZSIPP, believe that diagnosing and treating chronic pain patients constitutes the practice of medicine, and as such, belongs squarely in the scope of a full medical degree.
“Myself, along with colleagues from AZSIPP, are striving to educate our legislators that while the procedures we perform are safe if unqualified individuals perform them they can be dangerous,” he said.
In addition to concerns regarding outright safety and quality of care concerns, there is also the concern that without proper and extensive training, practitioners will not know the appropriate indicators to perform a particular procedure, which could result in increasing utilizations and driving up healthcare costs.
Chronic pain patients are a particularly vulnerable population, he added, which adds another layer of concern.