President’s Message: A Fresh Approach to Pain Education

Harry J. Gould, III MD, PhD

During the past 30 years, we have observed the prescribing habits of physicians swing from a position of avoidance of opioid medications in the late 80’s and early 90’s to a position of liberal and virtually indiscriminate prescribing of opioids in the first decade of this century.  This trend paralleled a similar rise in overdose deaths associated with prescription opioids that led to the development of Washington State’s Multiagency Guidelines for Prescribing Controlled Substances with the goal to improve the safety and effectiveness of opioid treatment for chronic non-cancer pain.  Concern about the over prescribing and overdose deaths motivated the Institute of Medicine’s investigation of pain in America, the Centers for Disease Control’s declaration that the “Opioid Epidemic”, was considered the greatest healthcare crisis in U.S. history and the release in 2016 of their Guideline for Prescribing Opioids for Chronic Pain.

The broad understanding and agreement that the problem exists coupled with a desire for a rapid solution led to varied interpretations of prescribing guidelines.  Imposed policies and benchmarks for treatment standards often exceeded the intended goals of the drafters of the guidelines.  Physicians’ fear of criminal sanctions and strict disciplinary consequences associated with failure to comply with guideline standards led to a dramatic decline in prescriptions issued for opioid medications.  Unfortunately, the rapid reversal of the pendulum related to opioid medications, while significantly reducing the availability of prescription opioid medications has not produced a parallel reduction in opioid-related overdose deaths and the pendulum representing improvement in patient care seems to have remained steady throughout this period of healthcare volatility. How can we move closer to our goal of providing appropriate and adequate care for our patients in pain and mitigate the problem of the untoward adverse effects of opioid medications on patients and on society as a whole? 

“Across health care and society alike, there are major gaps in knowledge about pain” was one of the important conclusions drawn from the Institute of Medicine’s investigation of the state of pain care in America.  This is an important focus, but moving the mark toward improved patient care takes time and a concerted effort from a vast number of healthcare providers who view the problem from varied perspectives and training, from administrators and regulators of practice standards and from the patients we are hoping to serve. Incumbent on the approach to developing strong, patient focused principles for pain management is understanding that there are many tools that are effective for treating pain, but not all tools are necessarily appropriate or effective for treating every pain problem.  Each patient should be properly evaluated and should be involved in setting reasonable goals and making decisions in their care.  The appropriate tool or tools for the problem and the rationale for implementation should be carefully selected and administered when optimum.      

To this point, a new program to address the problem of provider and patient education has begun a trial run at the Louisiana State University Health Sciences Center in New Orleans.  The program is a longitudinal study targeting physicians in training in various specialties.  The program is administered to residents-in-training across the entire spectrum of their training and focuses on pain as it applies to their specialty. It measures levels of understanding of pain, its evaluation and management at each level of training and as they progress through their program toward certification. The initial trial runs focused on residents in obstetrics and gynecology and in orthopedics.  As a point of reference, patient assessment and education is approached at stages of evaluation and planning, pre-operative instruction, intraoperative and post-operative care and discharge planning for procedures that are frequently performed or are particularly problematic within their area of specialty.  Issues related to pain, its management and patient education are discussed and reviewed in the laboratory including gross dissection and classroom with attending faculty with expertise in the basic science of anatomy, pharmacology and physiology and in the clinical sciences with specialty training in pain medicine, anesthesiology, physiatry, psychiatry and the appropriate surgical specialty.  Basic knowledge is assessed before and after each training session and will similarly be evaluated throughout residency training.  It is hoped that the participants in the program will gain a better understanding of how to better evaluate pain, how and why certain management tools are selected, when they should be applied and how to help their patients understand and participate in their own care. 

The cohort of trainees was selected because residents in training are at the steepest part of their educational growth curve where information provided and reinforcement of the basics is likely to have the greatest effect.  It is also appreciated that residents play a major role in mentoring and laying down the foundations of practice for medical students at the earliest stage in medical training and a level where the emphasis on training compared to the prevalence and influence on pain healthcare is very low. In this teaching role, the residents are likely to have challenges to newly learned principles and be able to reinforce what they have learned. Finally, residents are in a position to challenge and inform attending physicians of recent advances in arts complimentary to their specialty.  I am encouraged, thus far, with the progress that this program has made and look forward to the possibility that it may impact some of the negative perceptions that we inherit when embarking on a career in pain medicine.