Where have all the Tucson pain management docs gone? It’s time for the
primary care docs to step up to the plate,
By Jennifer P. Schneider
Published in the Sombrero [Magazine of the Pima County
Medical Society] Sept, 2007.
Having reached retirement age, I’ve been thinking recently about doing just that.
Not soon, but perhaps in a year and a half. Why the long lead time? Because
before I retire I have to find other doctors in Tucson who would be willing to
assume ongoing care for my patients with chronic pain. That wouldn’t be so
difficult if my patients’ primary treatment modality consisted of injections and
other invasive procedures; there are quite a few highly skilled pain specialists in
town who do procedures. But as it happens, I’m one of the few local physicians
who specialize in medical management of chronic pain. My patients are on
several
medications.
These
may
include
NSAIDs,
anticonvulsants
for
neuropathic pain and antidepressants. In my practice, most patients are also on
opioids. Many of my patients are stable and could certainly be managed by their
primary care providers, including writing for their opioids.
But that’s the problem – many primary care providers (PCPs) are
uncomfortable writing for opioids, even if they recognize that their patients are
benefiting. They would rather have the specialists write the scripts and take on
the risks of being visited by the DEA or scrutinized by the Arizona Medical Board.
No one can disagree that the regulatory environment for prescribing opioids for
pain is more challenging that for any other medication class. Even worse, some
PCPs in Tucson actually have signs in their waiting room announcing that these
practitioners do not write for narcotics. Woe to any of their patients who develop
significant pain! Other physicians mistakenly confuse physical dependence with
addiction, and erroneously believe that by prescribing opioids they will inevitably
turn their patients into addicts.
We now have a crisis in Tucson. Patients with pain, especially chronic
pain, are increasingly undertreated, especially if their pain can’t be alleviated by
invasive procedures. Primary care physicians are reluctant to undertake opioid
prescribing. Some of those patients whose pain is undeniable and significantly
impacts their ability to work and walk are being referred to the very few remaining
medication-oriented pain specialists in Tucson. We, pain specialists, in turn, find
ourselves increasingly being referred patients whose pain problems don’t need
our expertise – these patients could easily be cared for by their family doctor if
that doctor weren’t reluctant to prescribe opioids.. Patients with complex pain
problems end up having to wait weeks and months to be seen by a pain
specialist, because our schedule is already filled up with more patients than we
can handle.
And it’s only going to get worse. Several pain doctors in Tucson have
recently closed their practices or announced their imminent retirement. Some
have decided that it’s too much of a hassle to continue in a specialty that is
constantly under a microscope by government agencies and the media; others
have left pain medicine (or would like to!) after getting inappropriately disciplined
by the Arizona Medical Board for prescribing some arbitrary “excessive” dose.
After I retire, it is likely that there will be only one practice in Tucson taking new
patients for pain medication management in any significant numbers.
Part of the problem that PCPs have is that their professional organizations
have abdicated any leadership role in pain management. Neither the Arizona
Academy of Family Physicians, the American Academy of Family Physicians, nor
other primary care organizations have sought a political presence in the
professional pain associations (such as American Pain Society or American
Academy of Pain Medicine). In the ongoing dialogue between pain doctors and
the DEA, the professional PCP organizations have not taken a part. The lack of
interest in the PCP organizations then is reflected in the lack of interest among
PCPs in treating pain.
Moreover, the PCP leadership vacuum leaves PCPs
feeling vulnerable and unprotected if they do prescribe opioids. But by refusing
to treat pain and to be part of the solution PCPs are becoming a part of the
problem and are creating a liability potential for themselves. A backlash among
undertreated pain patients, lawsuits against physicians who categorically refuse
to prescribe effective pain medications, and collapse of the already overburdened
expert pain consultant network are increasingly likely.
Clearly an important part of the solution is for PCP professional societies
to take a greater interest and a more active political and educational role in
advocating for effective pain management.
This would be more in line with the
fact that in late 2000, Congress passed into law a provision, which the President
signed, that declared the ten-year period that began January 1, 2001, as the
Decade of Pain Control and Research. Primary care organizations should be
working to create the educational and regulatory environment needed to help
PCPs feel comfortable treating the pain that often accompanies illness, at least
on a basic level.
Given their fears of addicting their patients or being scammed, many
PCPs explain that they don’t have the expertise to use opioids for chronic pain.
These fears are legitimate, because opioids have abuse potential. Their use
requires appropriate evaluation, monitoring, and documentation.
Some
understanding of opioid side effects and of addiction, physical dependency, and
tolerance is needed. Guidelines for appropriate pain management have long
been available, but are unknown to many physicians.
In California, in accordance with the California Business and
Professions Code 2190.5, physicians with an active license need to obtain
12 hours of CME in pain management over 4 years. Arizona does not have such
a law. In Tucson, however, we now have a Pain Society of Southern Arizona. Its
members are pain specialists and PCPs who believe that the treatment of pain is
an ethical and moral imperative for all physicians. Our mission is to educate
primary care providers so that patients won’t have to depend only on specialists
for treatment of debilitating pain.
As the number of pain specialists in Tucson who prescribe medications
decreases towards nil, more patients will have to depend on doctors who are
currently hesitant to do so..
We invite all members of the Tucson medical
community to help solve a problem which belongs to everyone in the community.
As part of the solution, I challenge the Pima County Medical Society
(PCMS) to take the lead, along with ARMA, to bring the various stakeholders to
the table, especially our invites primary care professional societies. At issue is
Arizona citizens’ access to basic healthcare needs such as treatment of pain.
Additionally, as part of its educational efforts, the Pima County Medical Society
invites primary care physicians to attend an educational session designed to
make you more knowledgeable about the appropriate use of opioids in chronic
pain. The program will be held on October 22, 2007 at the Pima County Medical
Society.
I would like to thank Bennet Davis, M.D., for reviewing this article and
making suggestions.