SMART MEDICINE

Don’t blame opioids for the opioid crisis—doctors must become better at pain management

In the midst of a devastating opioid epidemic that has wrought addiction, despair and death in communities all over the country, the medical and scientific communities are reacting by questioning not only the prescription of opioids for treating pain, but the very treatment of pain itself.

This deeply misguided, if predictable, response threatens to deprive relief millions of Americans of relief from persistent, even debilitating pain. Instead of retreating from treating their pain altogether, we should focus on educating doctors on the multitude of safe, effective methods for treating pain in its various forms.

We should start by creating a set of standard guidelines or recommendations (a framework), like the compendiums that exist in every medical specialty, for pain treatment. Guidelines and recommendations have been published for opioid treatment. While they are a start, they are far our ultimate goals.

The lack of any such a framework is largely responsible for creating the opioid crisis. Lacking a useful set of standards for treating pain, and under pressure to treat pain byfederal standards, insurers and professional associations, physicians over-prescribed the only treatment they understood. Some drug companies exploited that knowledge gap, convincing lazy or unsophisticated physicians that opioids were the answer for all kinds of pain–and even, in some cases, that opiates weren’t addictive.

Now comes the predictable backlash. With vast populations of rural and urban Americans hooked on all types of opioids, but mainly heroin, Oxycontin/oxycodone, and methadone, attorneys general are suing certain pharmaceutical companies for illegal marketing practices. The American Medical Association is reversing more than a decade of policy of treating pain as the “fifth vital sign,” requiring the same sort of aggressive interventions as cancer or heart disease. That reversal would abandon legitimate chronic-pain patients, who shouldn’t suffer because of an incoherent policy toward pain management.

Pain medicine is seeing tremendous innovation currently, much of it led by options that aim to reverse the disease process. For example, combining specially derived stem cells with Clarix FLO Regenerative Matrix for pain, understanding the relationship central sensitization and pain, advancing on the relationship between the Stellate Ganglion and hot flashes, PTSD, CRPS, and other central pain conditions, new uses for radiofrequency ablation, and utilizing ketamine infusions to reverse negative neuroplastic changes. I have helped spearhead all of these amazing scientific advances, but have found that our progress has been obscured by confusion over opioids.

How we got here

The medical profession elevated pain to the status of life-threatening conditions in the early 1990s, but never followed up with the education and rigorous controls necessary to treat it. Every other medical specialty has detailed guidelines on how to treat diseases, based on hard science and clinical data to determine the proper balance of risk and reward for a given pharmaceutical or course of treatment. A cardiologist can read an electrocardiogram, consult practice guidelines, and come up with a treatment program that includes the proper medications in the correct doses for that individual patient. It’s relatively simple once you understand the algorithm, and if you don’t follow the guidelines you’re likely not considered a very good physician. Creativity is shunned in our profession.

Pain management isn’t nearly that simple. In fact, some would say that pain management is the most difficult specialty in medicine, especially if it is done correctly. First of all, pain can rarely be assessed empirically. Take a patient who says “my back’s been hurting for a few years, especially when I sit.” She has an office job, so that’s a problem. What’s the solution? There is no machine or blood test to tell the practitioner how much pain she’s in or what treatment would most effectively relieve it.

Without any objective guide, the treatment our patient receives will depend mostly on a proper history, physical, and patient feedback after treatments. An internal medicine physician might prescribe anti-inflammatories or a opioid like Norco. A surgeon might order an MRI and depending on the results, may recommend surgery. A rheumatologist might order an array of labs and give the patient an immunosuppresant. A Interventional Spine and Pain Management specialist, such as myself, might perform diagnostic procedures to isolate the pain and may offer any of the above options, interventional procedures for the treatment of pain, or an advanced treatment like ketamine infusions and stem-cell therapy.

All of these approaches could be valid, but not all of them are always valid for any individual patient. For example, opioids may be an option for a legitimate patient with chronic, debilitating pain that has failed to resolve with conservative or even aggressive treatment options. However, not all opioids are the same and they are certainly not a good idea for someone who has substance abuse issues.

Another big contributor to the problem is training, or the lack of it. There are no residencies in pain management, and while anesthesiologists can pursue a subspeciality fellowship in pain, few do. As a result, it is estimated that 90% of the “pain specialists” in America have no formal, accredited fellowship training in pain management. To put that in perspective, virtually all, if not all, cardiologists in America have completed an accredited cardiology fellowship.

It is hardly surprising certain pharmaceutical companies filled the educational void with false marketing. Some of these companies knowingly sold us products that released the medication to quickly, giving the patients a “high” that created cravings and addiction. Insurance companies still pay for these dangerous medications manufactured by these companies that made those false statements. There are pharmaceutical companies that have made a conscious effort in factual education and safer products. Ironically, insurance companies do not want to pay for their products and those company’s voices are rarely heard. Even worse though, insurance coverage for disease modifying options, such as stem cells and ketamine infusions, are slim.

What, and who, to blame for the opioid crisis

So don’t blame opiates for the opiate crisis. Stupidity and laziness among my fellow physicians play a role, as does opportunism by certain opioid manufacturers. I recently spoke to a local primary care physician who has been practicing for more than 25 years. He said he does not believe in pain management, diagnostic procedures, therapeutic interventional pain management, stem cells, or anything else because he refers to one pain management group (which he admitted was bad) and he hasn’t seen great results. Thus, he believes opioids are the best answer to pain management. I spent 45 minutes on the phone educating him about some of the facts and science and hopefully I helped him open his eyes. In any case, make no mistake, there is an absolute systemic failure with pain management education and delivery.

We can reverse the damage, and prevent the further spread of addiction. But we must educate doctors on the array of available avenues for treating pain, and provide them with a clear framework for which avenue work best for which ailments.

Before prescribing any treatment for pain, doctors must ask the following questions:

  • Is this a legitimate pain patient?
  • Am I prescribing legitimate pain treatment?
  • Am I a legitimate pain management provider and if not, who is a legitimate pain management provider in my area?
  • Have the medications been legitimately manufactured?
  • Have I considered all the possible modes of pain treatment?

Several years ago, regenerative medicine based on stem cells went through a backlash similar to the anti-opiate crusade today. The problem wasn’t bad therapies, but inappropriate uses and flat-out misinformation by physicians, many of them non-medical physicians such as chiropractors, hustling for a buck. Insurers backed away from a promising field because of the charlatans who were giving it a bad name.

Pain management is facing a similar crisis. It would be cruel and unnecessary for patients to pay the price, however. Chronic pain is torture and it terrorizes the patient’s brain. We know how to treat it, the challenge is spreading that knowledge across the medical profession.

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