It's the Pain Education Season, but We're Teaching the Wrong Lessons to Physicians

August 28, 2014

Looking back over a 30-year career in pain medicine, the author laments the shift from comprehensive, multidisciplinary pain care to a model that focuses on pills and procedures to treat chronic pain.

In the next 2 months, anyone interested in learning more about pain management will have at least 4 national meetings and 1 international meeting to attend: PAINWeek 2014, the annual meeting of the American Society of Pain Management Nurses, the annual meeting of the American Academy of Pain Management, a weekend offering at Stanford University by the American Academy of Pain Medicine, and the biennial meeting of the International Association for the Study of Pain. Choose between the meetings for information geared toward primary care providers, nurses, multidisciplinary practitioners, and researchers; each offering something unique, and all offering considerable information regarding safe opioid prescribing practices.

Frankly, I am concerned that there is so much information devoted to opioid prescribing and wonder what happened to the rehabilitative model proposed 40 years ago, and the focus on providing comprehensive care for people who have complex pain problems. Over the past 20 years the field of pain management drifted from comprehensive care involving behavioral methods, rehabilitation, and promotion of wellness, with an emphasis on coping, to monomaniacal care based upon administering a series of injections or a regimen of opioids, with little or no emphasis on rehabilitation, behavioral methods, or anything else. Care has been routinized, standardized, hybridized, but we still rely more on blocks and opioids with or without antidepressants and anticonvulsants for the majority of people seeking treatment for their pain.

I offer this stilted perspective because I am on the receiving end of so many treatment failures. I work as a psychiatric hospitalist, so I see the treatment failures from the community, not successes. I see people who take more immediate-release opioid than controlled-release opioid, who take homeopathic amounts of gabapentin, who have been prescribed combinations of medications that produce interesting and dangerous drug-drug interactions, and who always have anxiety and depression that is minimally addressed (if it is at all) by their “pain specialists.”

My patients tell me it is now easier and less expensive for them to obtain high-quality heroin for snorting, smoking, or injecting than it is to find licit opioids for sale on the street. I hear about their failed attempts to balance prescription opioids with heroin, alprazolam, lorazepam, clonazepam, and methamphetamine, but they never tell me about their prior use of behavioral therapies, exercise, stretching, physical or occupational therapy, benefit from proper nutrition, or even one attempt to wean from opioids to see if they still need these medications.

As I finish my third decade in pain management/medicine, I am perplexed to see so much illogical care, so much denial of what was clearly shown to work so well in the 70s, 80s, and early 90s. We finally recognize the risks and long-term consequences associated with injections, opioids, or any other form of monomaniacal care, yet we have no national agenda to offer comprehensive care for people who have complex pain conditions. Instead, we struggle to get prior authorization for some newer medication, procedure, or even a couple of days in the hospital after a failed suicide attempt.

I see statistics claiming that thousands of people are dying from opioid overdoses, hundreds are dying or sick from fungal contaminated steroids, tens of millions live with unrelenting and disabling pain, our returning veterans are strung out on prescription medications (assuming they get care at all), and the state of pain management education for most health care professionals is “brainstem” or minimal at best.

How is it that the number-one reason people go to health care providers for assistance is only minimally discussed during professional education? If 50 percent of primary care visits are related to pain problems, as is frequently described, shouldn’t more time be spent in professional education on such problems? If procedures and/or opioids alone don’t “cure” or adequately remit pain, shouldn’t more comprehensive methods be taught? At what point do we ask “What else can I offer my patient than just another injection or prescription?”

As you attend the upcoming meetings, ask yourself what you will do before you write the next prescription, perform the next injection. Will you consider a referral to a psychologist, dentist, chiropractor, acupuncturist, massage therapist, dietician, physical or occupational therapist, or someone else? Without being part of a comprehensive pain management program, can you cobble together the elements of a multidisciplinary pain program with two or three well-placed referrals? Would you consider being the “hub” for your patient, and “case managing” him or her through a series of referrals to create a “network” multidisciplinary program? Do you know a few providers in other disciplines who would agree to an occasional conference call to discuss challenging patients? Is there a workable solution?

I wish there could be more opportunities for collaborative care and reaching across disciplinary boundaries to help those in pain. I entered the field of pain management in 1985, naively hoping my lower back pain would be “cured” along the way. Thirty years later, my back still hurts, but now I also have joint pain, headaches, heartburn/abdominal discomfort, and the realization that as I get older it really does matter what I eat, that I adhere to a regular exercise program, stretch daily, do meditation, receive an occasional deep tissue/myofascial release massage, and get a few acupuncture needles strategically placed. I have stopped believing that complex problems respond completely to monomaniacal approaches and look for synergies where I find them; a little of this, and a little of that, 10% gain from this, 15% gain from that. It’s the combination that matters more than the individual components.

What do you think? Too outside the box for you? Send your comments to Editors@HCPLive.com.

B. Eliot Cole, MD, MPA, is a member of the Pain Management editorial advisory board. He has served in executive positions for several prominent pain management organizations and societies, including the American Society of Pain Educators and the American Academy of Pain Management. He has been a pain management fellow, clinician, educator, and advocate for nearly 30 years and has practiced in a variety of settings serving a wide range of patients.