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 (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.) 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.
Looking for a Dr. in Denver Colorado to manage my chronic pain nerve damage due to multiple surgery scar tissue pressing against nerve. I do not think it is fair for patient that are in pain fall into category of addict and have to pay the price of this so called epidemic. Please advise if this is a doctor in my area willing to stand up to the DEA and realize everyone’s pain is different not one size fits all. Thank you
So sorry to hear about the pain that you’re dealing with. We don’t have a doctor locator service on our website, but we would recommend visiting the Academy of Integrative Pain Management website at http://www.integrativepainmanagement.org/search/custom.asp?id=4552 as they have a “Find a Provider” page that may be able to help you.
One of the best ways to find a physician is by word of mouth, so you should also check with friends and family members – as well as people in local chronic pain support groups for recommendations for physicians in your area.
I feel so bewildered for all of us in this struggle! Yesterday, I was told by my pain management center that I had to ‘choose’ whether I wanted to take medication for severe panic attacks or my opiate pain medication! I have until April! I HATE medications, as much as the diseases and conditions I have been suffering with since a child! I didn’t ask to be severely injured working in a Orthopedic Medical Office; losing my abilities to work, have enough money to care for myself, and participate in most areas of everyday living! I desperately tried not to take pain medication, yet my conditions increased, causing the severity of pain to cry out for SOMETHING! I saw several pain doctors; all wanted to place me on a plethora of medications! I finally went to a spine center in my area! I eventually found a combination that I could tolerate! As the years go by with so many harmful interferences in my care, I decided to come down to a much smaller amount in medication! I still take a variety of long term use of Psychiatric Medication, including a benzodiazepine! These medications I cannot come off; my life requires this care! This National S&P Center was my champion, although comprehensive care was never implemented, didn’t exist! At least receiving medications, understanding my comorbid mental healthcare concerns, and having compassion once existed! Now, this vile, and completely misunderstood epidemic has me completely devastated!
I AM NOT AN ADDICT! I have bottles of unused pain medications I’ve destroyed! I remain in PAIN everyday! If I have to come off pain medications or not have the appropriate mental health medications, I will face suicide once again!
I was an advocate! I tried to be there for all of us in pain! Tonight, I need an advocate!
Excellent and well thought out information by Dr Payne. It’s horrid to be a victim of severe pain and be given a glib clueless answer by nurses and doctors. I am very concerned about the unintended consequences that result from easy answers that are not based on all the evidence , and the treatment that results from that . It leaves a lot of suffering.
Thank you Dr. Payne. If only you could call my doctor and make him as brave as you are, regarding us the victims of chronic pain. Mine is spinal cord nerve damage. From a chronic pain patient. Please help us. How and why do Government officials have so much weight to take our lives away from us?