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.