May 16th, 2016

Pain Medication And Addiction: Changing Our Approach

Recent editorials in The Washington Post and The New York Times focused on the need to address the role of physicians in the creation and correction of the continuing problem with opioid addiction in our communities. Although the relief of pain has always been one of the fundamental tasks of physicians, this receives surprisingly little focus in medical education. The lack of adequate education for medical students about the proper use of opioid medication for addressing pain has been cited as one of the several causes of the recent increase in opioid addiction. Even when medical schools make the necessary adjustment, however, physicians already in practice must still be educated.

In an ideal world, the issue of helping physicians keep their clinical work up to date is the responsibility of organized medicine. When this does not occur, government agencies step in. In 2008, I had the disturbing experience of witnessing such a failure. In 2007, the U.S. Congress was sufficiently concerned about the prescription opioid epidemic to pass the FDA Amendments Act, which expanded the powers of the FDA to address the problem. The FDA had to decide how best to use these new powers and invited “stakeholders” to a series of hearings to assist in making this decision.

I represented both the American Psychiatric Association and the American Society of Addiction Medicine at a few of these meetings. I heard bitter parents from across the country tell heart-wrenching stories of how their children had died because of the irresponsible prescribing of opioids by physicians, who were still endangering other patients by continuing these practice patterns.

To prescribe opioid medications, a physician must apply for a license from the Drug Enforcement Administration. Some of us supported a proposal that would require a physician to take a brief online test to demonstrate at least a basic level of knowledge about proper prescribing of opioids for pain rather than just writing a check to get the license. Failure to pass the test would require a remedial online course followed by a re-test.

I was disturbed that the American Medical Association (AMA) opposed this idea based on the argument that such “negative sanctions” would reduce the number of opioid prescribing physicians and result in unnecessary suffering of many patients with pain. The AMA counter proposal was to encourage physicians to educate themselves voluntarily. The organization worked aggressively to convince the other specialty physician organizations at the meeting to present a unified front by supporting its proposal.

The success of this effort to convince the FDA is documented by the “unexpectedly low” number of physicians who have since that time availed themselves of this voluntary approach. Unsurprisingly, states, such as Maryland, have stepped in and required all physicians to get one hour of opioid-related education as a condition of renewing their state medical licenses. Unfortunately, this mandate was applied even to those physicians who do not prescribe opioids. Because of the resulting protest, this requirement is in the process of being amended or rescinded.

It is not too late, however, for the AMA and other medical organizations to step up and do a better job than was done the first time around. The Center for Disease Control has already tried to fill the gap by releasing guidelines for the treatment of chronic pain. On May 11, the new president of the AMA issued an open letter to physicians supporting these guidelines. Such support is welcome, but the question is how much impact it will have. I expect that if organized medicine does not act more forcefully, we will once again see government agencies stepping in.

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