Violence Against Pain Care Providers: The Frightening Future of American Pain Medicine?

On June 1^st, 2022, a lone gunman, Michael Louis, walked into a medical office building in Tulsa, OK, and with a semi-automatic rifle and a semi-automatic handgun, shot and killed 4 people prior to turning his gun on himself and taking his own life. This was the 233^rd mass shooting in the United States in the first half of 2022,¹ and given the nation’s ongoing mass shooting epidemic, the story’s national interest waned quickly. Coverage by Tulsa’s leading daily newspaper, Tulsa World, continued, however, providing additional details of the tragic incident.²

Readers may be questioning the relevance of yet another mass shooting in the United States to the international pain community. The assailant, Mr. Louis, suffered from chronic low back pain, and among the victims were the orthopedic surgeon, Dr. Preston Phillips, who had performed a spinal fusion from L3 to S1 on the patient on May 19th, as well as another physician. According to Tulsa World, Mr. Louis was discharged from the hospital on May 24^th, subsequent to which he experienced ongoing pain for which he blamed Dr. Phillips. Tulsa police reported that they found a letter from the assailant stating that he blamed his surgeon for his ongoing pain and that he intended to kill him, as well as anyone else who got in his way. Mr. Louis reportedly contacted Dr. Phillips on numerous occasions between his discharge from the hospital and his final appointment with the surgeon on May 31^st. Although it was reported that Mr. Louis was distressed by his pain following his surgery, police reports indicate that he was also extremely unhappy regarding a number of functional deficits with which he was left post-operatively (Captain Richard Meulenberg, personal communication, June 24, 2022).

Reports from a number of media outlets were rife with assumptions and inaccuracies regarding the cause of Mr. Louis’s rampage. For example, the libertarian think tank, the Cato Institute, published a commentary in Reason less than a week following the shootings.³ In the commentary, the authors (both of whom are surgeons) claimed that “America’s Failed Opioid Policy Drove the Tulsa Shooter to Violence”. Another less-than-mainstream media source assigned blame to an Oklahoma state law that limits opioid prescribing to 7 days post-operatively.⁴ This claim is misleading, at best. According to the 2018 state law,⁵ initial prescription of post-operative Schedule II opioids is limited to 7 days, although the physician has the right to subsequently refill the prescription following the 7-day period. The speculation on social media regarding the relationship between Dr. Phiillips’ alleged failure to provide adequate opioid analgesia and the mass shooting tragedy was even more irresponsible and rife with unsubstantiated claims than that of the mainstream media, tabloids and blogs, which is hardly surprising.⁶ According to a source from the Tulsa Police Department, there is no evidence that the mass shooting was necessarily related to a failure to provide the perpetrator with adequate opioid analgesia (Captain Richard Meulenberg, personal communication, June 24, 2022).

According to a British tabloid with a reputation for less-than-perfect accuracy in its reporting, Mr. Louis was angry at his surgeon for having performed a “botched” surgery.⁷ Although multiple requests for clarification were sent to the author of the story, he failed to respond. The hospital at which the surgery was performed was contacted in order to obtain more accurate information, but we were told that they could not provide additional details with us based on the Health Insurance Portability and Accountability Act (HIPAA).

This tragic mass shooting was certainly not the first that may have been linked to oligoanalgesia. For example, in 2017, a chronic pain patient’s husband shot and killed her physician after he refused to prescribe her opioids.⁸ In 2021, a Minnesota man shot and killed one individual and wounded 4 others at a health center at which he received treatment for his chronic pain, with the gunman’s brother telling the media that he often complained about the “pain medication he needed and how they wouldn’t give it to him.”⁹ According to a survey of members conducted by the American Academy of Pain Medicine (AAPM) in 2019, more than 2/3 of responding members reported that a patient had threatened them physically at least once a year, roughly half reported that they had been threatened regarding their management of opioids, and 8.9% reported that they had actually been physically attacked.¹⁰ The authors of the study discussed risk mitigation against potential pain clinic violence, but how do pain care providers actually reduce risk in a nation in which access to semi-automatic weapons of mass destruction is essentially unregulated and unlimited?

Pro-gun rights individuals insist that access to guns in the United States is not the cause of the nation’s mass shooting epidemic, but rather the nation’s “mental health crisis” is to blame.¹¹ However, there are no records of impaired mental health for the assailant in the Tulsa shooting. In fact, a spokesman for the Tulsa Police Department noted that the gunman was “very deliberate about this”, as he only killed the physician he held responsible for his condition and those who “got in his way”, choosing to spare the life of a receptionist who was cowering at his feet (Captain Richard Meulenberg, personal communication, June 24, 2022). In a 2020 article on the manifestations of borderline personality symptomatology in chronic pain patients under stress, Shapiro, Kulich and Schatman noted that based on a diathesis-stress model, those suffering from Borderline Personality Disorders can potentially not manifest symptoms until the stress of chronic pain and its sequelae “pushes them over the edge.”¹² Given the findings of a review article by Sansone and Sansone in which the average prevalence of Borderline Personality Disorder among samples of pain patients was 30%¹³ and that borderline personality pathology has been found to increase the likelihood of homicidal ideation by 1557%,¹⁴ the risk of violence that pain care providers are currently experiencing cannot be overstated. This risk is, of course, exacerbated by the ease of access to semi-automatic weapons in the United States, a country in which the number of guns privately owned is considerably higher than the actual population, with 1.2 guns per capita.¹⁵ Perhaps it is not a coincidence that Oklahoma, where the recent mass murder of the physicians and others occurred, is a state with one of the higher rates of gun ownership in the country.¹⁶ Both the mass gun violence epidemic¹⁷ and the undertreated pain epidemic in the United States¹⁸ have been well documented, and our current societal instability suggests that this combination is an ugly one.

Although the incidence of actual deadly force against pain care providers is currently low, that the aforementioned AAPM survey¹⁰ indicated that approximately 9% of responding physicians had actually been physically attacked at least once a year raises concern that gun violence against providers relating to oligoanalgesia may become more commonplace with continued societal devolution. This may be a clear sign of the United States’ perpetually escalating opiophobia, and the need to reconsider the harm that is being done to patients¹⁹ along with all potential consequences of such. That 8.5% of the physicians responding to the 2019 AAPM survey¹⁰ reported carrying a firearm to work is frightening, and is perhaps as ludicrous as recommendations to arm all school teachers as a means of “solving” the school mass shooting crisis. In a recent article, Toutin Dias and Schatman noted that rates of severe burnout among American pain care professionals have reached a critical level, with progressively more leaving the field or retiring early as a result.²⁰ If gun violence toward pain care providers increases as societal stress continues to become more severe with further deterioration of societal mental health, is such a scenario not within the realm of possibility?

We acknowledge that this brief analysis is somewhat speculative, although data are provided. Irrespective, pain care in the United States desperately needs to improve, not only for the well-being of the nation’s 50 million chronic pain sufferers, but perhaps for those of us who try to treat them, as well.