As a specialist in pain management, I have witnessed the evolution of the opioid crisis firsthand. Day in and day out, I treat patients with chronic pain. I have seen enough to know that a lot of changes need to occur in order for the epidemic to begin to be fixed.
A “key” thing that needs to change is the perception of “what is pain management?” I often feel the public, as well as fellow physician colleagues, don’t understand what a board-certified pain management physician does.
A board-certified pain management physician is someone who did a one-year ACGME accredited pain fellowship. The goal of this fellowship is to train physicians who have completed a residency, typically in anesthesiology, physical medicine, and rehabilitation, neurology, psychology, and/or family medicine in comprehensive pain management. The one-year fellowship teaches these physicians how to treat acute and chronic pain, whether the pain is non-malignant or malignant (cancer-related). The overall goal of the training is to teach these physicians on how to do pain relieving procedures so they can better manage the patient’s pain without starting or increasing opioids.
I see new patients referred to me every day for pain issues. A common reason for referral is “my primary care can no longer or does not feel comfortable with continuing to prescribe me my pain medications.” They come with the expectation that I will continue to prescribe them opioids and possibly even increase them.
Proper opioid prescribing is one of my roles, but not my complete focus. My training has taught me to comprehensively work up a pain issue and then utilize several strategies to alleviate pain. Specifically, I employ pain relieving modalities, medications (over the counter vs topicals vs. non-opioid medication vs opioids), therapies (physical therapy, massage therapy, chiropractic care, behavioral health, etc), procedures (injections, ablations, and surgical implants) and referrals to surgeons when appropriate.
Modalities and medications are “passive” treatments. They typically “mask” the pain and do not treat the actual underlying pathology of the disease process causing their pain. Therapies, procedures, and surgeries, on the other hand, are “active” treatments. They can treat the pathology of the disease process and in some cases cure the patient.
I encourage all of my patient’s to take an “active” role in their care. I make it clear that the goal is to get them involved in “active” treatments which will hopefully improve their pain, increase their function, improve their quality of life, and minimize or eliminate the need for opioids.
Too often, patients are not open to treatments and just want the pain medications. Somewhere along the line, they were prescribed the opioids by a well-intentioned physician. I am sure they intended to give the patient pain relief while they worked up what was causing the pain and treat it. They did not expect the patient to become physically dependent or addicted. Surely, the physician did not expect that the patient would never want to “get better” and stop taking the pain medications.
Over the last decade, we have learned that using opioids to treat pain comes with a risk and clearly cannot be the first step in treating a patient's pain. As physicians, we need to educate our patients on taking an “active role” in their care and try to avoid starting opioids until all treatment options for a patient’s condition have been exhausted.