by Jonathan Clapp, MD, board certified AAPM&R and ABPM
Featured in the November/December 2017 Colorado Medicine.
Editor’s note: Colorado Medicine occasionally accepts and publishes opinion/editorial columns on topics of interest to Colorado physicians and consistent with topics associated with the Colorado Medical Society operational plan. The opinions expressed in all guest opinion/editorials are those of the author and do not necessarily reflect the views of the Colorado Medical Society.
I participated in a webinar in October during which pollster Benjamin Kupersmit outlined survey data from a recent all-member survey on the opioid epidemic.
The opioid epidemic is out of control. Despite efforts to curb opioid overdoses and deaths, they continue to rise. The latest U.S. national data indicates that drug overdose deaths increased 19 percent from 2015 to 2016 despite increased regulatory control and awareness surrounding the opioid epidemic. The need for improved education is paramount in limiting potentially dangerous opioids while providing adequate pain relief for the millions of people who struggle to meet vocational and family responsibilities because of their struggle with pain. We prescribe far more opioids than any other country in the world and efforts to curb this consumption have not yielded the desired results.
As pain physicians, we have additional training and certifications that show our proficiency in diagnosing and treating pain. Opioids are only one of the tools that we use. “Rational polypharmacy” is a mantra that we try to live by regarding the medications and supplements we prescribe. However, our primary responsibility is to diagnose the problem, treat it and maximize function and quality of life for our patients. Opioid pain medications are a part of many of these treatment plans, mostly due to the substantial pain relief that they can provide. Unfortunately, they are extremely dangerous and addicting. Knowing how and when to use them is critical in keeping our patients safe.
The size and consistency of this epidemic indicates a fundamental and pandemic problem across the country. In my humble opinion, based on academic literature and experience, education for physicians is that root cause. The American Pain Society published a study that showed U.S. medical schools offered only an average of 11.3 hours of “pain training” in some form compared to roughly 2.5 times that (27.6 hours) in Canada, where the overdose rate per population is roughly 2.5 times less than that of the United States. Pain is the No. 1 reason for all patient visits, but less than 1 percent of our training is dedicated to this complaint. The recounts of many non-pain physicians about pain training is eerily similar and mostly anecdotal. This story is typical: A medical student or resident asks their attending physician (who also only got 11.3 hours of pain training) how they manage pain and the answer is often as unique and surprising as the stories we hear regarding opinions on pain and opioids that often counter the available evidence and “best practice.” A formal course, or even single lecture, on treating pain in patients struggling with anxiety, addiction, high opioid tolerance, respiratory compromise and many other confounders are not common, if occurring at all.
Physicians are not the only ones with poor pain training. Nursing literature is riddled with calls for better education. One study showed, “Mean scores from the nursing knowledge and attitudes survey on pain revealed knowledge deficits and inconsistent responses in many areas related to pain management (mean, 62%; range, 41%-90%)”. Sixty-two percent, or a D minus, is not a grade anyone would consider acceptable to treat pain. In my personal experience, teaching over 100 nurses about pain has been eye-opening, as only two of them have raised their hand saying they received sufficient pain training to prepare them for what they see on their units and those two failed a pain knowledge test prior to my lecture, as did the rest of those in attendance.
Insurance providers and some in the pharmaceutical industry have also made profits off of our lack of education. Not knowing the evidence has made claims by aggressive pharmaceutical reps (for one company, in particular) harder to dispute, and case studies concluding it is safe to prescribe chronic high doses of opioids became widely accepted as fact. We all fell victim to these claims, but when the evidence came out refuting these claims, too many were unaware and did not change their prescribing habits. All insurance companies (commercial, federal and state) have inexplicably avoided helping our patients, but are quick to point out limiting opioids and setting up more barriers to getting them (and non-opioid treatment) when they are needed, hence protecting their bottom line. Pain is the only field of medicine where 20- to 30-year-old practices are still the standard with generic, cheaper and more easily abused medications being preferred over safer molecules or abuse-deterrent formulations. Claims that “we cover that medication” are often used, but are still prohibitively expensive and hence, useless. Addiction treatment, psychology and many other non-opioid pain treatments remain poorly covered and are critical to treating those who struggle with chronic pain and/or addiction.
Pain physicians have been stigmatized due to the snapshot of total morphine equivalents we prescribe, that are higher than other specialties. The reason for this, most of the time, is we inherit patients on high doses and often dangerous combinations of opioids, benzodiazepines and other sedatives including alcohol. It is our job, that we accept, to find a better and safer way to treat their pain and minimize risks. A better way to judge a pain physician is by how many morphine equivalents per patient they decrease from their initial visit and/or resulting improved function. “Do no harm” is an oath we take very seriously and we do our best to minimize risks while treating pain in patients who would be much less functional in their daily lives without pain treatment.
With the anecdotal and limited pain training we receive as physicians in general, please indulge me and imagine the following scenario: Insulin causes euphoria and addiction. Bear with me please! Insulin can kill people if prescribed recklessly and not using it is unacceptable due to the adverse effects diabetes causes to our patients. Replacing the words “diabetes” with “pain,” “insulin” with “opioids” and “endocrinologist” with “trained pain specialist” offers a new perspective on what is occurring and how problematic the reaction to the opioid epidemic has been. Please note, this is not meant to disparage endocrinologists, just to make a point to illuminate the problem in a new light.
Due to the widespread “insulin epidemic,” people are dying in record numbers across our country, some non-endocrinology trained physicians looking for a full and busy practice market themselves as “endocrinologists” only because they are willing to prescribe higher doses of insulin than most other physicians. Endocrinologists as a whole become stigmatized and subject to state medical board (mostly made up of non-endocrinologists with only 11.3 hours of diabetes training each) discipline due to the high quantities of insulin they prescribe. Over the next six to seven years, endocrinologists are thought of as “docs who just prescribe insulin,” “part of the problem” and excluded from conversations to try and fix the epidemic, despite their expertise. Admittedly, there are a few “bad endocrinologists” in cases where insulin may be easier to give than to look more into the problem and use “non-insulin treatments” like diet and exercise which are known to help decrease insulin use, but these cases pale in comparison to the number of “good” endocrinologists. The CDC publishes guidelines aimed at limiting insulin consumption and not treating diabetes. JACHO covers their website with a video and messages saying blood glucose checks being the “fifth vital sign” was never their intent and they are not responsible for the outcomes. Some states put in strict insulin unit dose limitations. The president declares a “national emergency” and physicians talk about removing blood sugar checks that (for the sake of this argument) can cause poor hospital scores and put physician careers in jeopardy for not treating diabetes. Physicians may feel pressured to prescribe insulin, because only 11.3 hours of diabetes training has resulted in less experience with other tools available to them to effectively treat diabetes. Metformin, diet, exercise and other treatments were never taught. And so, the pendulum swings towards not treating diabetes due to the fear of causing addiction or deaths by overprescribing insulin and the cycle repeats as it has over the past 125 years with everyone missing that there is a “sweet spot” in the middle of these extremes. This results repeatedly in two alternating epidemics: untreated diabetes and overprescribing.
We are physicians. That means we are public servants like firefighters or police officers. We are not to be concerned about customer service or surveys when the safety and best interests of our patients are involved. Being pain free is sometimes as unreasonable as someone who expects a cure-in-a-pill for their diabetes. When we are not taught sufficiently in a field we are forced to treat, we do what we know. That is all we can ever do. Unfortunately, our medical schools, residency programs, nursing schools and medical culture have failed us. Prescribing opioids is taught more often than basic pain concepts like opioid-induced hyperalgesia, opioid rotations, mu opioid receptor polymorphisms, avoiding opioids in neuropathic or central pain conditions, comorbid anxiety and depression resulting in two to five times more likelihood of being on chronic opioids at six months, utility of safer atypical opioids like tapentadol or buprenorphine, importance of new abuse-deterrent opioids, and concomitant use of benzodiazepines (which are first-line only for anesthesia purposes or alcohol and benzodiazepine withdrawals) with opioids resulting in a 10-fold increased risk of death than with opioids alone. 11.3 hours of training is not sufficient to prescribe insulin and it should be the same for opioids, at least for longer periods. This is a fundamental problem in our medical training, hence its widespread nature. We can do so much better! Learning pain management is not difficult, but it takes hours and hours of training, just as other specialties do. As pain physicians, we are thrilled to be allowed to come out of the shadows in this epidemic and offer our expertise (and each of our hundreds of hours of opioid and pain training) to a problem that WE CAN help mitigate.
I applaud the Colorado Medical Society for being one of the only state medical societies in the union to look to us for our opinion. We welcome the challenge and are confident we can offer better answers than those that are in play currently.