I have been in family medicine long enough to see cycles of change in management of several conditions: diabetes, heart attacks, even tonsillectomies. But none of them seems to compare with the changes I’ve seen in the last 20 years regarding the management of pain. Somehow, primary care physicians seem to be at the center of this climate shift. As the current president of the Iowa Academy of Family Physicians, and as an educator of young physicians, I want to reflect on the shifting winds and their impact on our practices.
As a medical student in the 1980s, I don’t remember much training around the use of narcotic pain relievers, other than the basic pharmacology about receptors and mechanisms of action. Unlike what I was taught about antibiotics or antihypertensives, there was no weight-based dosing or a level of pain at which to give the medication. I learned by watching how the residents and attendings treated pain. Most of them were conservative in the use of narcotics.
When I started practice in the late ‘80s, I followed that conservative approach. However, about 10 years post-residency, just as I was starting to feel comfortable with most of my medical decision-making, there was what appeared to be a concerted effort on the part of eminent physicians and accrediting agencies to accuse me and my peers of lack of empathy for my patients with acute and chronic pain. We were all “re-educated” that pain was the fifth vital sign and that we needed to treat that vital sign with the same alacrity we would treat an elevated temperature or tachycardia. The literature provided to us at the time seemed to support aggressive pain management in prevention of such dreaded conditions as causalgia (now called complex regional pain syndrome) and post-herpetic neuralgia. Our “re-education” included an introduction to long-acting narcotics, which were touted as a better way to dose pain medications than the peaks and valleys of pain relief afforded by short-acting opiates. We were even given toolkits and books, provided free of charge by foundations funded by pharmaceutical companies and distributed to us by our own state medical boards!
In the ensuing years (early 2000s) we also were admonished to be cautious with non-narcotic pain relievers. Nonsteroidal anti-inflammatory drugs put patients at risk of irreversible kidney disease. Some of them increased a patient’s risk of a heart attack, not to mention GI bleeding. Acetaminophen dosing caused liver disease. Medications for neuropathic pain like tricyclic antidepressants caused sedation at best or cardiac arrhythmias at worst. Some non-opiates were put on the BEERs list to be used with caution in the elderly. Steroids cause osteoporosis. Opiates seemed to be the least risky alternatives, if you could put up with the annoyance of constipation. For those of us working in safety net practices like community health centers, the cost of newer adjuncts for pain relief, like duloxetine and pregabalin and referrals for epidural injections, were beyond what our patients could afford.
Also in the interim, changes brought on by fast adoption of EMRs, increased employment of physicians, and an infusion of mid-level practitioners like physician assistants and nurse practitioners (often with full prescribing rights) created new patterns of practice and new pressures on primary care physicians. Those physicians were to be overseers of a primary care team, but also expected to handle complex cases, a high patient load AND the new patients brought in by the Affordable Care Act.
Fast-forward to 2014 and a report by the Agency for Healthcare Research and Quality (AHRQ), when there appeared to be evidence of an epidemic of narcotic overdoses and allegedly high numbers of narcotic prescriptions being written by primary care providers. This was noticed by both physician groups and by the state and federal governments, and each party brought its own perspective to bear on the crisis. Physician groups and thought leaders in the medical profession worked for voluntary education efforts and tools that helped the prescribers know how to assess patients for at-risk behaviors and patterns of misuse of narcotics. State government imposed mandatory training on pain management. The local and national media contributed heart-breaking stories of addiction and death, which added emotional fuel to what was beginning to look like a firestorm.
The federal government appears to have a more deliberate, and in my view, a more reasonable approach to this crisis. The Centers for Disease Control and Prevention and its sister agencies in the National Institutes of Health studied the problem and put together a rational approach to the problem, consistent with their background in science and evidence-based decision making. They also asked major stakeholders such as physician groups and patient advocates to assist with the process. It took more than a year from the AHRQ report to publish their response. The results were out last week and provide primary care physicians and their teams a set of guidelines and tools, along with the evidence supporting them, to use in their approach to patients in chronic pain.
I look forward to a vigorous discussion of the content of these guidelines and will be honored to hear from Des Moines University alumni on their perspectives of the different aspects of the guidelines.