It's the Pain Education Season, but We're Teaching the Wrong Lessons to Physicians
AUGUST 27, 2014
B. Eliot Cole, MD, MPA
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.