A fellow physician recently shared a frustrating clinic visit with me, in which a patient had left by saying, “You doctors need to wake up and realize that patients (who are) in pain are in a no-win situation.”
The patient was absolutely right. This summer, the Institute of Medicine released a report, “Relieving Pain in America,” which found that 116 million Americans suffer from chronic pain, costing the U.S. up to $635 billion in treatment and lost productivity. Chronic pain even increases the risk of depression and suicide.
But when it comes to treating pain, doctors also face no-win situations. While chronic pain is effectively treated with opioids — a class of medications that includes morphine and OxyContin, as well as heroin — close monitoring of the patient is essential because the drugs can be addictive.
In a column in TheNew England Journal of Medicine last fall, physician Susan Okie noted the explosion in the sales of pain medication, as well as a marked increase in emergency room visits for pain drug overdoses. In fact, according to the Centers for Disease Control and Prevention, deaths from unintentional drug overdoses in the USA, primarily driven by opioids, are the second-leading cause of accidental death.
To combat prescription drug abuse, the Drug Enforcement Agency has gone primarily after rogue doctors, pain clinics and wholesale drug companies. Still, highly publicized federal raids can discourage honest doctors from prescribing pain pills. In TheNew England Journal of Medicine, physicians Timothy Quill and Diane Meier said “concerns about regulatory oversight have led some physicians … to avoid prescribing opioids entirely and have rendered others … fearful or hesitant.”
Doctors face a conundrum. On the one hand, chronic pain drugs can lead to abuse, which could draw the attention of law enforcement. On the other, chronic pain patients are often inadequately treated. It’s not because doctors don’t care. Robert Rolfs, state epidemiologist at the Utah Department of Health, calls prescription drug abuse “an unintended consequence of an intent to treat pain better.”
States taking action
One answer to the dilemma is to regulate pain management, as Washington state is doing with new rules to be fully implemented by Jan. 2. Opioid prescribers will be required to use a patient and drug monitoring program and to practice under uniform pain management guidelines.
Another answer lies in better education of both physicians and patients. According to the American Society of Interventional Pain Physicians, 80%-90% of physicians have no formal training in prescribing controlled substances, such as pain pills. Primary care doctors, who encounter chronic pain patients more frequently, need to be fluent in dosing and monitoring the use of pain pills as well as recognizing the signs of abuse. A proposal by Sen. Jay Rockefeller, D-W.Va., would require physicians to participate in specialized pain management training before being licensed to prescribe controlled drugs, such as pain killers. That is a step in the right direction.
And pain management needs to be incorporated into medical education. Only five of the country’s 133 medical schools today have required courses on pain.
More patients suffer from chronic pain than those with diabetes, cancer and heart disease combined. Similar attention and resources that we use on those better known conditions should also be spent on better educating doctors and patients about chronic pain.