Physicians One Part of Needed Systems-based Approach to Chronic Pain

As many of you know, we are in the midst of an epidemic of chronic pain and abuse/diversion of oxycodone. Oxycodone now kills more people than cocaine and heroin combined, and has left a sordid trail in Ohio, Florida, and Maryland. I have witnessed many lives deteriorate because of oxycodone-related issues. Who is to blame? Doctors? The drug itself? The patients? Well major relevant organizations such as the American Pain Society and the American Association of Family Physicians regularly publish articles and editorials emphasizing that main is often undertreated, precisely because of prescriber fears related to abuse/diversion. Moreover most doctors are aware of the importance of treating pain, but are even more aware that narcotics aren’t the sole answer, despite what many patients believe.

We need to have a systems-based approach to chronic pain. That doesn’t mean automatically refer chronic pain patients to a pain specialist. In fact, the Medscape “Chronic Pain in America” series emphasizes that pain specialist referrals should only be made if the patient’s problems require more than what the primary-care provider can offer; (this suggests a larger point that consultants should only be called when their services are needed, not immediately upon elicitation of the chief complaint - I only call consultants when a patient is deteriorating under my care or for a procedure I cannot do myself).

Systems-based approach means an approach mutually agreed upon by all interested parties - physician, medical board, insurance company, patient, etc. Many problems in the treatment of chronic pain are related to these multiple parties not being on the same page. For example, I recently discharged a patient from my service in the hospital with prescriptions for long-acting opiate medications and a short course of short-acting narcotics. The patient is informed upon leaving that their insurance company would not pay for the long-acting medication, so I replaced it with another long-acting medication, trying to stick to the least expensive ones. As the patient’s pain worsened, it eventually dawned on him that his insurance company would not pay for any long acting narcotic. But the pain guidelines emphasize the need for long-acting agents in the use of chronic opioid therapy for chronic non-malignant pain. The patient had uncontrolled pain at home, and within one week, came back to the emergency room, and was re-admitted.

Maybe this was my fault for discharging him before working out all the inane details related to what his insurance company would cover and what it would not. But frankly, the hospital isn’t the place to work this out - it should be done in the primary-care physician’s office. Of course, his primary-care physician has no interest in providing narcotics to this patient, who is clearly dependent on them for management of chronic pain. Here is an example of how primary-care physicians need further training in the management of chronic pain, and this can be achieved with online CMEs.

Pain specialists may do spinal injections and other fancy procedures of dubious value, and their credentialing perhaps has more merit in the courtroom, but as I say above, they should not be first in line in the treatment of chronic pain with narcotics. An internist or family physician should be able to do that, using a multi-modal approach to chronic pain involving methods that have been shown to be effective- exercise training, stretching/yoga, nutrition, prolotherapy, psychotherapy, emotional freedom techniques, and the multiple pharmacologic agents at our disposal.

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