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.
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Insightful, intelligent and very articulate! We are in the middle of a very uncomfortable transition in chronic pain management. Physicians and chronic pain patients alike are distressed and anxious. Doctors with experience are having their judgment questioned and doctors without experience are suggesting that the safer path for the patient may be living without pain relief. That suggests to me that your best option may be relying on your apparent good judgment.
I have chronic pain and am on opioids and it is a nightmare trying to get proper help in Northern Ontario. I don’t have addiction or mental health problems. It takes weeks to get a family doctor appointment, which is unacceptable. I would like to add medical cannabis to my pain treatment plan, but if I do, my physician will stop prescribing opioids. I am very frustrated. Any suggestions? Thank you.
Are today’s physicians prepared to treat chronic pain?
Kriti,
First, congrats on being part of the next generation of doctors, and a heartier congrats on demonstrating more thoughtfulness on the subject than a lot of MDs who’ve been in practice for 20 years.
The truth is, once you’re in practice the guidelines and educational programs are barely worth the paper they’re printed on. Not because a lot of thought research hasn’t gone into them, it has. Rather, all the evidence in the world is meaningless when you’re face to face with an individual patient. You’re going to need to trust your instincts, accept that you’ll make mistakes, and be unafraid to ask for help. Chronic pain patients are the most challenging to deal with in medicine. At both the individual and societal level, pain is so inextricably tied to problems of mental illness, addiction, and drug diversion I don’t know if they’ll ever be solved.
That said, your awareness that there’s a “hidden curriculum”/cultural bias at play is the most reassuring sign your future patients could ask for.
Hi Kriti
You are absolutely correct in your assertion and the gaps in training related to chronic pain and chronic disease management in general. As a senior policy analyst in a chronic disease portfolio it was a challenge to have physicians and other HCP integrate non-pharmaceuticals into a treatment plan. This is due to a number of factors-expectations of the patient of a “quick fix”, fee for service payment models and non-coverage for non-pharma treatments or waitlists for programs. Our chronic disease self-management programs -based on the Stanford Model were free and offered across the province. These ought to have been a go to as a recommendation but most didn’t know about them or what the skill building content of the program included. Sadly conversations and coaching are not well renumerated and encouraging patients to set functional goals as the person not provider lives with the illness takes time and a shift in practice.
Since leaving government, I work with non-pharma organisations to educate health care professionals on a number of issues related to chronic disease. Particularly chronic pain and addiction. The Prescribing Course-Safe Opioid Prescribing is offered across the Atlantic Provinces by the Atlantic Mentorship Network – Pain and Addiction. It is supported by a number of organisations including Doctors Nova Scotia and Workers Compensation Board of NS and NB. The WCB funds all Dalhousie Family Medicine residents in their 2nd year to attend. It is the first initiative of its kind in the country. Further info is available @ http://www.bluesmartieconsulting.com or contact me @ info@bluesmartieconsulting.com