Over the first two years of my medical training, I have been bombarded with information about opioids and chronic pain – much of it occurring outside my formal schooling. Media reports in my social media feed, conversations with peers, and even documentaries have attuned me to the evolving crisis.
In the classroom, on the other hand, I’ve had a few hours on the basics of prescribing opioids for chronic pain, and even less curricular time regarding non-pharmaceutical treatments for pain, such as exercise, yoga, tai chi, and transcutaneous electrical nerve stimulation (TENS). The psychological component of pain, for example the correlations between depression, anxiety and chronic pain, has hardly been addressed. My experience is not unique: a small study of North American medical and physiotherapy students found that pain education is generally lacking in volume and breadth in relation to the bio-psychosocial factors that contribute to pain and non-pharmacological management.
As someone about to begin actively caring for and working with patients, I feel ill-equipped and nervous about managing patients with chronic pain. I’m not alone.
Among my classmates, there is hesitation and uncertainty around general management of chronic pain and prescribing opioids, much of which stems from a justifiable fear of creating or fueling addiction. Many tell me they feel comfortable prescribing opioids for palliative care, but not for chronic, non-cancer pain. This is not uncommon, even among practicing physicians. But given that 15-19 percent of adults suffer from chronic pain, this is a concerning gap in managing non-cancer pain that we need to address.
Globally, studies have shown that medical students share similar fears and concerns, especially around deciding whether a patient is actually suffering from pain or is a “drug seeker.” This dichotomy is unnerving and symptomatic of our educational approach. It can not only lead to improper treatment of pain, but also undermines a sense of trust, which is at the base of the therapeutic relationship between physician and patient. It likewise illustrates a lack of understanding of appropriate pain management, since opioids are not first line therapy for the treatment of chronic non-cancer pain.
A 2011 Pain Medicine study noted that medical students often describe their encounters with chronic pain patients as negative, frustrating and unfulfilling, stemming largely from the complexity of a chronic pain patient’s care and the frequent feeling of being unable to help. This is worrying given the prevalence of chronic pain and the suffering it can cause.
A recent scoping review conducted by Canadian pain specialists discusses a historical shift from “opiophobia” to overprescribing in medical education, noting that in the early 2000s, medical trainees were encouraged to prescribe more opioids in the management of pain. By the early 2010s, research in medical education started to focus on safe prescribing and on the higher risks of using opioids.
Throughout this time, however, the breadth and depth of medical education on chronic pain and its management seems to have gone largely unchanged. One Canadian medical school developed an interprofessional pain course that brought students from six faculties together. But this course was later criticized due to significant ties to the pharmaceutical industry and lack of disclosure of conflicts of interest. Feedback I received from course participants suggested that the program emphasizes interprofessionalism more than the reality of chronic pain care.
There are a variety of ways to improve education on chronic pain and opioids. Formal curricula could be modified to include more time for chronic pain and opioid teaching, with more emphasis on non-pharmaceutical management and the psychological impact of pain.
We need to address the “hidden curriculum” of chronic pain and opioids, the tacit learning that is defined by the culture, systems, and institutions around an individual. The very fact that we discuss addiction and diversion of opioids as much as we talk about the psychosocial factors of pain is part of this hidden curriculum. It sets the stage for beliefs surrounding chronic pain in our patients. Recognizing the impact that this hidden curriculum has on our development as physicians and our ability to care for chronic pain patients would be a huge step in mitigating its negative effects. We need our teachers to model the best methods of first line chronic pain management so that students going through their clinical rotations are exposed to and taught more than just treating with prescriptions.
We are living in a time when trainees are fearful of chronic pain, and where media reports and social media have become de facto educators about the opioid crisis and chronic pain. This alarming trend should give medical institutions a strong impetus to modify curricula to focus on the psychosocial aspects of pain and non-pharmaceutical management. This will contextualize the use of opioids, the pain they treat, and the patients who may be prescribed them. This could help to transform an unqualified fear of opioids into a healthy appreciation of their benefits and risks, thus setting their proper place in the management of certain pains.
The author would like to thank the Canadian Federation of Medical Students for ongoing funding and support of medical student research and advocacy surrounding the opioid crisis. Kriti had the support of Abhimanyu Sud in writing this article. Dr. Sud practices in primary care as well as chronic pain medicine. He is a Lecturer in the Department of Family and Community Medicine and also Academic Director of the Safer Opioids Prescribing program at Continuing Professional Development, both at the University of Toronto.