Last year John Branch of the New York Times wrote a three-part article entitled “Punched out: The life and death of a hockey enforcer”. The article opened eyes to the physical and mental toll the enforcer role could take. Off the ice Derek Boogaard wasn’t just an affable giant who protected his teammates and raised money to send kids to hockey camp. He struggled with the pain of injuries he’d been accumulating since he was a kid, and he handled that pain with massive doses of narcotics.

 Len Boogaard struggled to understand what happened to his son, and this week John Branch documented that fight. Len tried to piece the story together through Derek’s medical records from teams, private doctors, dentists, rehab, and pharmacies. Sometimes he got the records, sometimes he hit walls. Even with an incomplete picture, and team doctors unwilling or unable to comment, it was overwhelmingly clear that Derek Boogaard had been receiving incredibly fragmented care from multiple doctors across several states and at least one province. He was herded into one of the most common and deadly addictions in North America by a group of people who had sworn an oath to care for the sick with warmth, sympathy, and understanding. An oath which also specifies that those people are not to play at God.

It is obvious that the medical culture of the NHL is broken. Boogaard didn’t have a primary physician to oversee his care. He didn’t have the proper follow-up on his addiction treatment. Nobody was checking to see how many prescriptions he was filling. Doctors continued to prescribe the very medications that had sent him to rehab, and which eventually killed him. And all in the name of getting him back on the ice.

The question of whether a physician employed by an NHL team can provide care uninfluenced by anything other than what’s best for the player is enormous. The treatment decisions of “regular” doctors aren’t made in a vacuum – they’re influenced by what insurance will pay for, what the patient wants, and what the scientific literature has decided is the current standard of care.  NHL doctors have the added contributions of players who lie to get back on the ice, teams that want their highly-paid employees back at work, and fans that aren’t interested in waiting two years for Sidney Crosby to get better.  Obviously there are plenty of excellent doctors in the NHL. Doctors who care about their players’ minds, bodies, and futures, who stand their ground and refuse to clear someone if they’re not ready, and who lose sleep wondering if they’ve made the right treatment choices. Those aren’t the doctors we hear about, and that’s fine. In medicine the old cliché holds true and no news is good news. The glaring issue is that if every team physician followed the NHL’s injury guidelines to the letter, the NHL would quickly find new doctors.

For now let’s set aside the question of how to fix the NHL’s broken medical management. I’ve thought about it for months, and I don’t know the answer. It won’t be simple, and it won’t come from a blog post. Let’s accept for now that the system doesn’t work, and look more closely at what may have been its greatest failure to date:

 

Why did Derek Boogaard have to die this way?

 

Boogaard had a pain problem. A huge one. He’d broken bones, hurt his back, and taken blows to the face and head for years. Physical pain aside, the mental toll of going to work every day with the aim of hurting others and being hurt can’t be measured other than to say it must have been enormous. Derek wanted to play, so he had to manage his pain. In the short term, opioids (like the hydrocodone and oxycodone he was so often prescribed) are extremely effective painkillers. In the short term. They bind to receptors in the brain that make your body think the pain is better. They don’t treat it, they don’t fix it, they just make you think it’s bearable. The underlying problem causing the pain is still there. Opioids also contribute to increased amounts of dopamine in the brain, dopamine being a neurochemical with significant roles in both pleasure and addiction. Opioids are an excellent way to ease the pain of an injury while it heals. Opioids are prescribed for fractures, dental procedures, surgeries, and every other pain-causing problem you can imagine. In the short term they work well.

The issue with opioids is that if you take them for an extended period of time, you’re going to build a tolerance. With chronic pain and opioid use, the way your body processes pain signals changes. You start to need larger doses to achieve the same effect. If you haven’t addressed the problem that causes the pain, there is no reasonable endpoint. As damaged as Boogaard’s body was, it’s possible there wasn’t a way to fix his pain. Masking it with opioids was the wrong solution. Patients with chronic pain are hard to treat, and patients with both chronic pain and an opioid addiction are a nightmare.

In Boogaard’s case, there were limited options.  If his pain couldn’t be treated and he wanted to keep playing, they had to find a way to manage his symptoms. Pain management is an unpopular medical subspecialty, and for good reason.  As a pain management physician it’s your job to attempt to tailor a program of medications and other therapies to keep someone who is in constant pain functional, hopefully without turning them into an addict (although many already are). Some patients do extremely well, and can maintain a near-normal life. Some people never find their solution.  As a patient, it’s easy to hate your pain management doctor. Their job is to tell you no.

 

Nobody told Derek Boogaard no.

 

An intensive pain-management program isn’t compatible with an NHL career. Boogaard was receiving escalating doses of opioids, drinking, and taking Ambien. Ambien is a popular medication in the addiction and pain crowd. Pain keeps you awake. Ambien puts you to sleep. Ambien is also addictive, and like opioids it builds a tolerance. Physicians who oversee drug and alcohol treatment programs often refuse to prescribe it, believing that replacing one addiction with another is completely counter to the philospohy of rehabilitation. Multiple league and private physicians continued to prescribe both Ambien and opioids to Boogaard, and although oversights existed, they were inadequate.

While several states and most provinces have safeguards in place to prevent inappropriate prescribing, Boogaard’s money, access to multiple physicians and mobile lifestyle made it painfully easy to beat them. He filled prescriptions in Minnesota, New York, and Saskatchewan, and he bought prescription medications on the street.

The Minnesota Prescription Monitoring Program aims to identify patients who are filling controlled substance prescriptions in inappropriate amounts or frequencies. Pharmacies are required to submit daily data on precriptions they’ve filled. Sounds great. The problem is that physicians are not required to make their names visible in the database, there is strong legal language discouraging using it to find inappropriate prescribers, and pharmacists are not required to check it before filling prescriptions. There are also exemptions available for a variety of circumstances, and data is purged after a year.

New York had no such provisions at the time Boogaard was filling prescriptions. Technically it still doesn’t. Just this week the state passed legislation allowing the creation of a database requiring real-time reporting by pharmacists, and requiring that physicians check patients against that database before prescribing controlled substances.

Saskatchewan has a relatively advanced prescription reporting system. Since 2000 the province has been building a database of every prescription filled. In 2006 the province created a list of prescription drugs with the greatest potential for abuse, and began identifying individual patients whose prescription-filling habits were inappropriate. The physicians who are prescribing the medications are then contacted. This system addresses the base reality – these drugs don’t come out of a pharmacy unless a doctor somewhere issues the order to dispense them.

 

Therein lies the problem. 

 

Several doctors gave Boogaard access to opioids in inappropriate amounts, monitoring programs were (and are) not as strict as they could be, and most importantly – prescriptions are irrelevant when you buy your drugs from dealers. Again it bears repeating that opioids never make it out of a pharmacy (and thus onto the street) without a doctor’s order. Multiply Derek Boogaard’s prescription history with every other doctor-shopping addict, every post-op patient that doesn’t use their whole prescription, and every ER patient with a “really, really bad headache, doc”. The sheer numbers of opioids out there rapidly reveals itself to be staggering.

Branch points out in this week’s article that Boogaard received 622 pills (in 25 total prescriptions) in six months (hydrocodone and oxycodone). That’s actually about five months worth of pills if he was taking one every six hours. But that’s one pill every six hours for five solid months without missing a single dose, to include getting up at night to take a pill, and that’s ridiculous. Numbers like that in a patient who isn’t participating in some form of managed pain control are amazing. Worse yet, doctors in New York issued Boogaard precriptions for opioids after he’d been through the NHL Substance Abuse and Behavioural Health Program.

I absolutely refuse to accept the argument that Boogaard chose his path. He wanted to play hockey. He didn’t want to hurt, and he didn’t want to be an addict. He was surrounded by practitioners completely willing to prescribe substances so dangerous that the government literally dictates the wording of the prescription and exactly how refills are given. He found ways to get his pills on the street from dealers profiting from the fact that the US consumes more opioids per capita than any other country, to the tune of 240 million prescriptions per year. While the majority of physicians who do the prescribing likely do so in good faith, it is irresponsible not to do one’s due diligence and investigate as fully as possible what a patient’s narcotic profile is before giving them something that can very easily kill them.

Due diligence and good faith have no place in the explanation of why doctors continued to prescribe to Boogaard after he’d been to treatment, and when it was painfully obvious that he was struggling. Derek Boogaard died a preventable death because nobody told him no.