ESP: Emerging Solutions in Pain

An interpretation for primary care
by Sunil J. Panchal, M.D.

This article talks about some concepts in regard to health care personnel and advocacy for patients. Regardless of the therapeutic area, people involved in clinical care environments have mostly chosen this type of work because they enjoy helping people. They believe in the type of care options they provide and believe that they are helping the patients in their care. For most therapeutic areas, the relationship between caregivers and patients are reasonably straightforward. However, in the area of pain medicine, these relationships are more complicated. Therefore, when discussing advocacy for patients requesting pain treatment, I would encourage everyone to take a balanced view.

In the past, advocacy efforts related to patients with pain have always focused on increasing the availability of opioids to patients that request them, with very little emphasis on ongoing assessments to determine if opioid treatment is warranted or even effective beyond a short timeframe. Instead, the “advocates” have pushed for open-ended treatment solely based on patient demand. Every other area of medicine evaluates the effectiveness of the medication prescribed to determine if it should be continued or not. If we do not advocate for a rational approach for pain therapy, and we do not advocate for a balanced approach to the treatment of pain (meaning that opioids are not always appropriate for every patient requiring analgesia) then we will never gain the respect of our colleagues in other areas of medicine, reasonable concepts for treating pain will not gain adequate acceptance, and patients may not receive the best possible care.

For primary care physicians to be effective advocates for patients with pain, one must become familiar with pharmacologic approaches to pain treatment as well as procedural approaches, and have an understanding that they are not mutually exclusive. Patients must be adequately assessed to arrive at the best diagnosis causing the symptoms of pain, and then must be educated on the appropriate options available for therapy, even if some options cannot be provided by the clinician as they may be outside their scope of training. When it comes to opioid therapy, we must have a balanced understanding that issues such as abuse and diversion are real phenomena and cannot simply be ignored. We must advocate for appropriate screening and monitoring of patients who are on opioid therapy, institute measures to ensure appropriate compliance, and not ignore risk factors such as abuse of other substances by the patient, or other individuals in their family, or close friends. We must insist on seeing an appropriate response to therapy to justify continuing it. In short, we must significantly improve the assessment and care of these patients to achieve better outcomes, and therefore ensure the continued availability of the full spectrum of treatment options. This is the best way to be an advocate for pain patients; anything less than that will ensure the continued dismissal of the efficacy of pain therapy from our colleagues, and allow examples of undertreatment
to continue.

I do feel optimistic about the direction of this field as there continues to be significant innovation in treatments for pain under development, and the fellowship training programs that are graduating individuals trained in the broad spectrum of pain therapies continue to be fully subscribed. Primary care physicians are perfect candidates to be pain patient advocates.