By Richard Payne, MD – PAINS Project Medical Director

Richard Payne, MD, Medical Director
John B. Francis Chair, Center for Practical Bioethics
Esther Colliflower Professor
Medicine and Divinity, Duke University

The ongoing tragedy of opioid overdose deaths—now reaching 42,000 in 2016 by some estimates—continues to generate much attention. A “Perspectives” column in the January 3, 2018 issue of the New England Journal of Medicine titled, The Public and the Opioid Abuse Epidemic, was included by the Journal’s editors in its “most notable list for 2017,” i.e., “as being among the most meaningful in improving medical practice and patient care.”  The authors, Robert Blendon and John Benson,  at the Chan School of Public Health at Harvard, examined data from seven national polls to determine how the public views the opioid abuse crisis and what they think should be done about it. Some of the results were surprising.

The researchers at the Harvard School of Public Health found that, “A majority (53%) of the public considers addiction to prescription pain medication a major problem nationally; of note, 33% of respondents to a Politico-Harvard School of Public Health Poll summarized in this same article, “Blamed…doctors who inappropriately prescribe painkillers.”1 Most of the respondents in these polls thought the most effective strategy for addressing the opioid crisis would be to increase pain management education and training for medical students and doctors—and this follows logically from the major source of perceived blame for the problem.

There is wisdom to targeting professional education in pain management as a strategy to address the opioid overdose crisis, to the extent that some patients may not be appropriately evaluated prior to starting and maintaining opioids for chronic pain management. In the Relieving Pain in America report of the Institute of Medicine (now National Academy of Medicine) we noted that pain management is not emphasized enough in health care curricula, and “…despite the large role that care of patients with pain will play in their daily practice, many health professionals, especially physicians, appear underprepared for and uncomfortable with carrying out this aspect of their work.”2

Another important report developed professional consensus on four domains of competency that are needed to manage pain in a holistic and comprehensive manner that “address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models.”3 However, as many people have noted, the availability of clinical practice guidelines and pain education activities alone, focused on improved opioid prescribing, are not by themselves, adequate to fully improve pain management.4 It is important that the CDC evaluate the efficacy and possible unintended adverse effects of its recently released opioid prescribing guidelines for chronic pain.5

Patients need much more than better-educated doctors and nurses. Both patients and providers need comprehensive pain management centers that provide medical, physical, neurological and psychological assessments of patients and has the facilities and resources to implement comprehensive care plans that provide access to physical and behavioral therapies that are integrated with pharmacological therapies, including opioids and other medications. The irony is that these centers existed in the past and demonstrated their efficacy in improving important patient outcomes such as improved function and improved abilities to cope with pain with a reduction (but not complete abstinence) in medication consumption.6 It is important to note that the efficacy of multidisciplinary pain treatment centers has been known since the 1980s, yet these practices eventually disappeared because they ultimately were not supported by insurers and health plans.

We need to look back to the future to re-create fiscally sustainable comprehensive, rehabilitation-focused pain management centers. Of course the re-establishment of comprehensive multi-disciplinary pain centers should be combined with providing state of the art, evidence-based and unbiased education about acute and chronic pain at all levels of professional development—students through post-graduate training and continuing education for established and licensed clinicians. This is a critical step toward achieving PAINS vision of providing high quality and cost-effective pain management while reducing opioid consumption.

1 Blendon RJ, Benson JM. The Public and the Opioid-Abuse Epidemic. NEJM, January 3, 2018: 10.1056/NEJMp1714529
2 IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies
3 Fishman SM, Young H, Arwood EL, Chou R, Herr K et al. Core Competencies for Pain Management: Results of an Interprofessional Consensus Summit. Pain Medicine 2013; 14: 971–981
4 Victor TW, Alvarex NA, Gould E. Opioid Prescribing Practices in Chronic Pain Management: Guidelines Do Not Sufficiently Influence Clinical Practice. The Journal of Pain, Vol 10, No 10 (October), 2009: pp 1051-1057
5 CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Recommendations and Reports / March 18, 2016 / 65(1);1–49 ( Accessed Jan 15 2018
6 Turk DC. Clinical effectiveness and cost effectiveness of treatments for patients with chronic pain. Clin J Pain 2002;18:355–65.

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