Pain physicians are currently in a no-win situation

Pain Management, May 2012, Volume 5, Issue 3

Publisher's note, May 2012.

Physicians today who treat patients for pain, especially primary care physicians, could be forgiven if they complain they suffer from whiplash, given how quickly the conventional wisdom regarding opioids has been reverse

Doctors have been told that they should consider pain to be the “fifth vital sign” and that all patients deserve to have their pain taken seriously and treated aggressively, lest the doctor receive poor marks on patient satisfaction surveys. Despite the fact that many physicians have been ill-prepared by their medical education to effectively assess and manage the patients who present to them complaining of chronic pain, they have relied on their professional judgment to provide good-faith care to people with legitimate medical needs (though some patients are not always themselves acting in good faith). They’ve been told that they need to spend as much time as necessary with chronic pain patients in order to conduct a thorough exam and assessment that takes into account all possible physical and psychosocial factors before prescribing opioids, and then to diligently follow-up frequently with those patients, all while practicing in an environment that allows for less and less time to be spent on any one patient. They’ve also been instructed to meticulously document every statement, decision, and justification for treatment in each patient’s record, in case their care fails to pass muster according to the notoriously opaque standards of state or federal regulators.

These physicians have also been told that they must regularly avail themselves of the latest CME and other educational offerings, as well as the latest published research, to bolster their ability to provide appropriate and effective care to patients with chronic noncancer pain, especially when it comes to prescribing long-term opioid therapy. The message that many physicians received from this was that their (and their patients’) fears regarding opioid addiction and dependence are unfounded, and that responsibly prescribed opioids are a vital component of effective management of chronic noncancer pain.

All of these messages from advocates for pain patients, physician educators and professional societies, and others had an effect, and the great majority of physicians did the best they could with the tools and knowledge at hand. Now attention has shifted from the undertreatment of pain (though studies and surveys continue to reveal that patients’ pain is undertreated across settings and demographics), to the overprescription of opioid medications for pain.

Now the narrative is that many physicians are too cavalier when it comes to prescribing opioids, often administering them to patients who receive little benefit, and are unaware of the risks associated with long-term chronic opioid therapy. This change in physicians’ attitudes and prescribing habits, so the story goes, has created an environment in which so many people have received “medically appropriate” prescriptions for these medications that the ready supply of opioids in the nation’s medicine cabinets has ballooned. This in turn has contributed to a huge increase in prescription opioid-related deaths among people who misuse these medications (and who overwhelmingly are frequently not the ones for whom the prescription was written). Because of this, all physicians who treat patients for pain are under greater scrutiny, despite the fact that a relatively small number of clinicians are responsible for a large percentage of the schedule II opioid prescriptions written in this country. And now comes word that the federal government is intent on investigating the financial relationships between the makers of opioid medications and several national non-profits and professional societies that, the government alleges, have improperly promoted “a body of dubious information” regarding the use of opioid medications through “prescribing guidelines, patient literature, position statements, books and doctor education courses” (http://trib.in/JkwIUf).

One minute doctors are being told that they’re not doing enough to treat pain; they need to educate themselves from reputable sources and do a better job. The next they’re told they’re doing too much to treat pain and now they’re responsible for an opioid epidemic. Now they’re being told by the government that the sources of their information may be suspect, throwing everything into an even greater state of confusion. Where this ends up is anybody’s guess.