Praveen Ganty is a Consultant in Pain Medicine & Anesthesia in Toronto
There is a new fashion in the world of Medicine, and in the world of primary care in particular. It is the reluctance to continue prescribing, or to prescribe, opioids. There are two sides to the situation. As medical professionals, we have realized the potential harm that opioids can cause to potentially any patient, especially if prescribed for chronic non-cancer pain. However, many of us have also decided to stop prescribing opioids to patients who have been on them for many years, which raises some concerns. The first principle in the practice of Medicine is Primum non nocere-first do no harm – (modified to ‘first do no further harm’ by some authors).
Managing chronic pain is not easy and – let’s face it – most of us don’t have enough training in this area. A 2011 survey revealed that only an average of 19.5 hours are devoted to the management of pain in an average medical school curriculum. It should come as no surprise, then, that Medical School graduates may not be experts in recognizing, diagnosing and treating a pain disorder. Patients with chronic pain should not be treated as if they have acute pain. True, patients with chronic pain have acute exacerbations, and patients with uncontrolled acute pain can develop chronic pain, but treating patients with chronic pain as if they were having an exacerbation is a root cause of our current problem. We all know, and appreciate, the role of opioids in managing and controlling acute pain. This should not be extrapolated to chronic pain in the community. They are, and should be, treated as two entirely different entities.
The problem gets more complex when very few residents in Family Medicine programs are interested in chronic pain. Added to that is the average 10-minute consult that a patient has with a family physician, and we have a situation wherein the doctor has limited information from the history, and can only make assumptions about the diagnosis and should prescribe something, especially if there is a repeat visit for the same problem. The simple answer-prescribe an opioid. ( It is heartening to know that the situation is rapidly changing with the College of Family Physicians setting up easily available resources on its website to help its members- and is investing more time into training and updating family physicians on the management of chronic pain). The patient takes the opioid or sticks on the patch, depending on what was prescribed, and notices some relief, but not alleviation of the pain. This is followed by the logical step-increase of use. Before we know it, we would then have a patient “addicted” to opioids, yet who continues to be in pain. The desperation becomes evident on both sides of the consultation desk. Add to that the “bad press” that opioids have been getting, and the news that they have been prescribed indiscriminately, the classic reaction is to stop the opioid as soon as is possible, or in many cases, to refuse prescribing refills. Yet acute withdrawal from opioids can be more traumatic – both physically and mentally – to the patient than the pain was in the first instance. This leaves the patient with few choices; a typical patient then goes on a search for a more sympathetic family physician who would continue to prescribe “the only medication that has helped with pain over the years”.
It’s a complex scenario, but as physicians we have only ourselves and the medical treatment model to blame for both the current opioid crisis and the resultant opiophobia that is now a trend. The way forward, to resolve the current opioid crisis and resultant opiophobia, is not only effective regulation by the regulatory bodies, it is also education, and the responsibility to keep ourselves updated. We have a responsibility towards every patient to offer the best we can professionally. To deny someone a pharmacological treatment simply due to “bad publicity”, is inappropriate. It is best to refer to a specialist, or someone with an interest in chronic pain, who has the time, and the resources, to set right this complex problem.
I wish doctors and politicians could discriminate between people who buy opioids and fentanyl so that they can have a party and be high, and those who have physical causes for their pain and knee treatment. If people started partying with insulin, would diabetics all of a sudden be restricted ? The vast majority of people dying of overdoses are dying from recreational use of opioids.
I’ve been living with chronic pain since 2012. After several years of waiting 6 to 10 months for the next specialist to assess my situation, I’ve become quite disheartened. With the help of the Internet, my postgraduate education in health care, I’ve found a possible cause for my pain and other symptoms. However, because I use opioids in order to be as functional a possible, I’ve not been able to get expert diagnostic and therapeutic care. So I have two choices, stop the opioids and be unable able to take care of myself while I wait months or years for a specialist appointment, or continue to take the opioids, manage my pain, work part time and hope that some doctor triaging my referral might consider that I could have a treatable condition.
The longer I’m denied appropriate assessment and treatment, the longer I’m going to need to stay on opioids. I don’t fit the overuse, potential addiction model. I continue to work as much as I can, I’m not on welfare, I’ve not asked for disability support. I’d really just like to get better. After waiting a year to attend a pain clinic, I was sent to some questionnaires. After reading them I realized that I was not going to get any care at the pain clinic. The focus of the questionnaires was assessing if I was a drug seeker or abuser. Was I just depressed, unhappy, looking for government handouts? Several questions indicated that the goal of the pain clinic was to get me to accept that I would not get better, and I would just have to get used to it. So it’s not surprising that I decided I was not going to use what little energy I have, spend money I have very little of, to waste it on attending a pain clinic, which in reality has nothing to do with helping me manage my pain. What I need is diagnostic and therapeutic care. But because I’m a middle-aged woman, my pain is viewed as a tool I’m using to get attention.
Before my head injury, I worked full-time had many activities and hobbies, lived in active life.
It’s unacceptable for physicians to not be interested in becoming competent in managing chronic pain. It’s not an option. It would be like saying oh I don’t want to take care of people with high blood pressure, diabetes, heart disease, hemorrhoids. There are multiple tools out there to assist doctors to assess opioid use, these are tools that have been validated and are evidence-based. Why are doctors using them?
As a registered nurse I am apalled by the lack of physical assessment performed by the various specialists I’ve attended in the last few years. Two years after this started, one resident took my pulse. It was found to be quite high. That was in 2014, after doing some research it appeared that my head injury may have caused me to develop POTS, orthostatic tachycardia syndrome. Two years later I was seen by a cardiologist, he declined to do the appropriate testing. Said I might have pots, but in the letter to my family doctor he indicated that he thought it was just because I was a hypochondriac nurse. In 2018, I was seen by another cardiologist, he ordered a tilt table test. in 2018, I was seen by another cardiologist, he ordered a tilt table test. This confirmed that I do have POTS. which fits with many of my other symptoms and history of my injury. I’m going to spend the next several years trying to get the appropriate testing and treatment.
Stop blaming patients. Chronic pain can be managed with opioids. When I say managed I don’t mean treated cured. I do mean that people are not totally disabled by pain. After performing activities that trigger my pain today, I was unable to eat, read or do anything but curl up in the dark, and wait for the opioid medication to work. I didn’t premedicate myself with the opioid, because I am under strict limitations of how much I have available. I know that I’m going to be in pain after doing certain things, but in order to limit my use of medication, I hope that this time it might not cause pain, and then I won’t need to take the opiods.
In my profession, I see way too many people that have been dealing with chronic pain. In most cases, they only get subscribed pain meds that don’t solve their pain problems.
There simply is not enough “credit” being given to just how disabling chronic pain can be, much less the financial and personal problems seen as taboo among the healthy, which mount despite being even more crippling when exacerbated by the first. From this perspective, navigation of the medical system can be extremely difficult, if not entirely impossible. As a chronic pain patient a year short of 30, I have struggled to obtain the appropriate treatment from a very young age. Even before I was diagnose with AS, I was suffering horribly from headaches that persist to this day. The medical systems misunderstand/general lack of education, regarding pain management or the loss of function associated with, has been the number one struggle of management/stability I have experienced. Once a patient suffering from moderate to severe pain (a majority of the time, regardless of cause) enters the system, the forces of negatives and positives it applies on the patient when utilized “by the book”, result in the patient often coming to rest where they originally started or worse. This lopsided treatments becomes more out or round /lopsided as time goes on. While the disease process is progressing and the treatment evolving , the patient is becoming increasingly focused on obtaining the relief they need to function properly. Eventually the patients condition is so lop sided, that the average doctor/clinician cannot decipher between the person desperate for relief and the demeanor of a drug addict. After decades of study/observation regarding my own condition, I have grown surprisingly sympathetic of the clinicians position. But the current atmosphere most chronic pain patients are greeted with, much less the lives they are forced to live (or not live really), is an absolute hell on earth and completely unacceptable. Doctors MUST champion the fight as they are the only ones acreditted to. BUT, regardless of accreditation… this fight will always ultimately be for someone else, given our laws regarding conflicts of interest…and that’s the biggest problem. My generation lacks MUCH empathy and has been brainwashed by negative opioid propaganda to boot. I can very easily see this piece’s claim of the interest lacked in pain management by residents. When a person looks at the patients they see daily, yet hear the direction/fear they do regarding opioids , the only logical conclusions to come to are A: We do not currently have the technology required to treat the pain these patients are claiming B: Pain of the caliber which requires our current pain killer arsenal idoes not really exist, or is extremely rare and only found in dying people. Very rarely will they question whether the direction itself is inaccurate, as they are there to learn. Now if a person like myself has the energy and pain management required of the level of pain my disease process offers…the information being taught to me would not only, quite obviously be lacking certain imoptant points, but the foundation of which would appear significantly flawed/counter productive. I am terrified as a “young” person, to see the generation of doctors who will come to rule of my generation. The generation who lived through the confusion and misinformation propagated by the opioid epidemic and the war on drugs. I fear bumpy and painful existence knowing the severity of my pain now, and the fat that will only increase, despite limiting me to a life of conflicting responsibility and broken dreams. Doctors and politians around the world must know that the current rules and restrictions applied to opioids are rendering the treatments near useless, creating an excruciatingly painfull purgatory here on earth. Its a life not worth living
Thank you for your thoughtful comments.
Dr.Mathur, you could consider referring your patients to our clinic. If you do a ‘Google search’, you may find us, but please note that this blog was not meant to be an advertisement of any sort. I concur that the first, and the best, line of defence, would be the family physician in this battle against opioid misuse. Given the propensity of chronic pain in the community, waiting lists are something that need to be accepted.
Thank you, Dr.Miler, for your kind comment.
Dr.Chalfin, I concur with you that logistics, and many other constraints actually hamper in caring for a patient suffering from chronic pain, especially in remote locations. This is where the Provincial Government(s) should step in to invest in appropriate resources. This problem is not unique to Canada- in the UK, many peoples in the remote areas of the England, Scotland, Wales and Northern Ireland have minimal or no access to services in chronic pain.
Dr.O’Neill, thank you for your very thoughtful comment.
To clarify, here is the one of the references that I based my comment on: Zoberi KS, Everard KM, Antoun J. Teaching Chronic Pain in the Family Medicine Clerkship: Influences of Experience and Beliefs About Treatment Effectiveness: A CERA Study. Fam Med 2016;48(5):353-358. There is another article from 2010, and here is the citation: Yanni, L. M., McKinney-Ketchum, J. L., Harrington, S. B., Huynh, C., Amin, BS, S., Matsuyama, R., … Garufi-Clark, L. (2010). Preparation, Confidence, and Attitudes About Chronic Noncancer Pain in Graduate Medical Education. Journal of Graduate Medical Education, 2(2), 260–268. http://doi.org/10.4300/JGME-D-10-00006.1
Although the latter surveyed only some programs in the US of A, the theme was similar.
I agree that we need an objective and comprehensive Program for Family Medicine residents and Practitioners that deals with the management of chronic non-cancer pain. I am willing to support any such venture, and I am confident that there are more talented and well-known personalities in the world of chronic pain in Canada, who would want to work on this initiative. Perhaps, the Royal College would consider an online program, with webinars and tutorials to be set up?
I find the suggestion that “very few residents in Family Medicine programs are interested in chronic pain” absolutely baffling. An enormous amount of ‘garden variety’ family medicine encountered in residency involves management of chronic, non-cancer pain. I could not find a survey of family medicine residents about their desire to learn more about this but given its preponderance in daily practice I can not imagine the author’s assertion is accurate. I say this as a current family medicine resident.
The core issue from my perspective seems to be a dearth of high-quality, independent (i.e. not sponsored by ‘insert drug company here’) education for primary care practitioners on pain management. Referring to a specialist is never going to be an appropriate systems-level answer to the management of a common problem, other than in rare cases. When something is so common, it needs a primary care level solution.
Unfortunately, the options for treating chronic pain in BC are limited. Physio is not covered; most other adjunctive pain management therapies are not covered, and I have seen patients wait as long as 4 years for an appointment with a pain clinic. To add insult to injury, we are on a small island where patients are given travel vouchers for the $40 + ferry ride for off-island appointments only if the trip is for an MSP-covered service, so they have to pay for travel as well as for the non-covered service.
I am interested enough in pain management that I went to a chronic pain management CME. It turned out to be mostly about fluoroscopic injections, which are obviously not relevant to a family doctor without access to fluoroscopy!
What’s a family doc to do?
It would be better to increase training in chronic pain for family doctors so that they could provide treatment.
Chronic pain clinics in the Greater Toronto Area tend to have outrageous waitlists and have an even greater opiophobia than primary care providers, preferring instead to send the client off to mindfulness seminars and/or CBT. Could you please provide me with some options of where to send patients?