Dr. David Casarett: Pain Management
A Pain Management Crisis
A tragically high number of people in the United States are in pain, both physically and emotionally. In the past few years, the prescribing of pharmaceuticals for mollifying or eliminating such pain, including opioids and other controlled substances, has reached epidemic proportions.
As access to these drugs become more restricted, an unintended gateway has opened for newly created addicts who move on to illicit street drugs such as synthetic opioids (fentanyl), black tar heroin and others. This unfolding calamity is happening across the country and destroying families at every income level.
The inadvertent consequences of pain management have been devastating and the statistics are grim. According to the National Institute on Drug Abuse, in 2016 more than 42,000 deaths were related to opioid overdoses, including synthetic opioids (fentanyl), prescription opioids and heroin. That number rose to 47,000 in 2017, the most recent available data.
As the nation’s pain eradication crisis continues to mushroom, the availability of a potential solution some call a “miracle drug” is also escalating rapidly. State by state, the U.S. is moving steadily towards the legalization of the cannabis plant for medical and recreational purposes.
The nascent medical marijuana industry, already valued in the multi-billions, comes with the potential for enormous benefits and risks in the context of patient care.
Amidst such uncertainty is a steadying force, Dr. David Casarett, the highly accomplished and experienced physician taking a lead role in providing sound advice to those in search of answers. Let’s meet this medical man with the well-considered plan.
The Medical Man’s Background
Dr. David Casarett has been a notable, award-winning palliative care physician and health services researcher for over two decades. He is laser focused on improving systems of care for people with serious, life-threatening illnesses, especially pain and symptom management. His sole objective is improving his patient’s quality of life and end-of-life decision-making.
Casarett completed his medical training at Case Western Reserve University and the University of Iowa, including a master’s degree in medical anthropology at CWRU, followed by fellowships in ethics at the University of Chicago and in palliative medicine at the University of Pennsylvania.
Afterwards, he worked as a hospice medical director and assistant professor in the Division of Geriatric Medicine at the University of Pennsylvania. He was also a staff physician and medical director of the palliative care service at the Philadelphia VAMC.
He currently resides in North Carolina and is a professor of medicine at Duke University School of Medicine and chief of palliative care for the Duke Health System.
The definition of ‘palliative’ is “relieving pain without dealing with the cause of the condition.” In other words, easing a person’s pain is the primary objective rather than curing the illness. Usually aligned with an end-of-life plan, it allows a person to die in comfort and dignity and is most often associated with the care given in a hospice facility.
In addition to a leading expert in relieving pain, Dr. Casarett is by every measure an erudite, soft spoken and compassionate man. He’s exactly the type of doctor I’d want at my bedside when facing the inevitability of end-of-life pain management decisions.
Among his primary focuses has been in shifting the traditional care model away from emergency rooms and hospitals to home care – the place where most individuals would prefer to either recover or spend their last days on earth.
He is intent on improving decision-making for patients and their families, including using pain medication safely and disposing of unused prescriptions before they cause unintended problems.
In a Christiana Care speech, dated December 20, 2013 (available on YouTube), Casarett says “Every time you get to a hospital you get worse – you feel weaker, more tired, more anxious. Bad things happen at hospitals and it’s the one place you want most to avoid.”
He is a creative and humorous speaker, using examples from history and everyday culture to connect with the audience and make his points. His message though is earnest: No one with an acute and chronic diagnosis who is suffering pain should need to call 911 and take an ambulance to an emergency room. This is a scenario happening all too often and is a complete failure of the system.
“Staying at home comfortably and safely is the goal,” he says. “It increases patient satisfaction markedly while saving the medical system a fortune. But it takes creative, thoughtful advance care planning.”
Every human being wants to retain control over their own lives. It’s a fundamental need. At perhaps the most uncertain period of their lives, their failing health, people crave certainty. Dr. Casarett continually stresses the vital importance of giving the patient control of their healthcare plan to the greatest extent possible.
When you become a pain medication addict, you’ve lost control of your life. When you go to an emergency room and are admitted into a hospital, you’ve lost control of your life. Casarett has been working for years to change that, by studying the market trends and listening carefully to what his patients want.
“They want control over their illness,” he says. “It is frightening to be totally dependent – to lose control of your health, your care, your very life.”
He has discovered a way to give his patients a measure of the control they so crave. Since 2015, he has been advocating for and prescribing medical marijuana for their pain management.
Medical Marijuana – Benefits & Risks
In studying the best ways for chronically ill patients to relieve nausea, pain and anxiety, Dr. Casarett believes two things: One is that opioids and other controlled substances are necessary, but dangerous if misused. Two is that medical marijuana holds enormous promise as a potential substitute for pain management.
In his 2015 book Stoned: A Doctor’s Case for Medical Marijuana, he acknowledges the unknown risks and the critical need for more research with the most common derivatives of the cannabis plant, cannabinoids THC and CBD.
Casarett reports relieving his own back pain using marijuana, but also experienced hallucinations and confusion. “Marijuana and driving do not mix,” he says, highlighting just one of the many risks involved with this new frontier of medicine.
There is a dearth of information on several essential safety issues, Casarett believes, including proper dosing and timing, the varying effects on different patients, and the efficacy of using CBD for patients who want the pain relief without the sense of euphoria that comes from THC.
“There’s no question that the decades-long war on drugs has set back the research efforts in marijuana,” he has said. That appears to be changing now at a revolutionary pace, which is good news for pro and anti-cannabis communities alike.
Several of Casarett’s patients, and others, have told him time and again that they’re using marijuana effectively in treating disorders including seizures, PTSD and neuropathic pain. Importantly, they report regaining a sense of control over their treatment plan and no longer feeling as frightened and totally dependent on the system.
A controversial anti-cannabis book was released in 2019 by author Alex Berenson called Tell Your Children: The Truth About Marijuana, Mental Illness and Violence. It has been supported by many and greeted with howls of protest from pro-cannabis supporters as replete with faulty data and conclusions.
As the legalization and medicinal process marches ever forward, consumers are best served to hear a balanced view of both the benefits and risks, so we fully support the research and lively debate continuing unabated.
Delivery of Patient Care
Dr. Casarett has surprising opinions worth considering on the delivery system of medical marijuana care. Dispensaries, many of them small mom & pop shops, are providing their patients better education, care and service than multi-billion-dollar companies in the traditional healthcare system.
“When I visited several dispensaries to research my book, I felt the folks behind the counters were there for me,” he says. “They asked questions about my medical history, goals and fears, and they listened patiently. They were generous with their time in explaining the various strains and their effects. The personal care they showed me was extraordinary compared to most doctor’s offices and hospitals. While it’s embarrassing, it is also an opportunity. Hopefully, it’ll be a wake-up call.”
The Medical Professor & Author
In addition to his day job Dr. Casarett is a prodigious writer, having authored over 100 articles in medical journals and other mainstream magazines. In addition to Stoned, he’s written two other nonfiction, ‘end-of-life’ books, Last Acts and Shocked. He’s also authored two novels in the ‘Ethical Chang Mai Detective Series.’
Whether he is writing medical research, nonfiction or fiction, his critical reviews have been generally superb.
Of Stoned, the Washington Post has said, “Anyone considering whether to use marijuana for a medical condition will find this book a valuable introduction to becoming an educated consumer.”
Of Rooster Happiness, author Ian Hamilton says, “A wonderful debut novel full of the sights, sounds and senses of Thailand mixed in with one hell of a great plot and a heroine – Ladarat Patalung – who stays with you long after the book is closed. Bring on the second in the series.”
His research articles have been received with great acclaim, including being presented the ‘Presidential Early Career Award for Scientists and Engineers,’ the highest honor attainable.
Clearly, this palliative care specialist is a tireless, multi-talented writer and medical man.
While this may be the end of this story, it feels like just the beginning for this multi-talented and industrious physician.
As we enter the summer of 2019, the nation’s opioid crisis continues to make headline news almost daily. The medical field, from drug producers to physician prescribers, are bearing the brunt of the blame. There is a race underway to improve the system and find alternative, less-addictive therapies for pain management.
Squarely in the middle of this unfolding drama and ready to serve is one David Jonathan Casarett MD. We’ll be watching the next steps of his extraordinary career with interest while listening carefully for his sage advice.