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As opioid epidemic worsens, rethinking how doctors are taught to treat pain

April 17, 2016 at 12:59 PM EDT
Pain is the most common reason that people go to the doctor. Yet physicians and medical students have limited training in pain management and prescribing opioids. As the nation suffers from an opioid epidemic, people within the medical field are reexamining what doctors are taught about pain. NewsHour Weekend's Christopher Booker reports.
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BY: MELANIE SALTZMAN AND SASKIA DE MELKER

As the number of U.S. prescriptions for opioids doubled over a 15-year period from 105 million in 1998 to 207 million in 2013, the number of fatal overdoses from the drugs soared almost five-fold, from 4,000 deaths a year in 1999 to nearly 19,000 in 2014. That includes people who illicitly used prescription opioids and those who overdosed on pills prescribed for them.

The problem has been building since the 1990s when a shift occurred in pain management. While traditionally medical professionals avoided opioids for any pain treatment, many doctors began using these medications a quick solution to a patient’s pain.

“There was an entire movement and I was being told that we had an unrecognized epidemic of pain in America,” Dr. Joseph Zebley told PBS NewsHour. “I think I, like many others, were fooled into at least partially believing that and starting to write prescriptions more liberally.”

Amid the growing epidemic, many doctors also don’t learn much about pain management while in medical school. A 2011 study found that during four years of training, a typical U.S. medical student spends only nine hours learning about pain.

In turn, some in the medical community, with increasing pressure from regulatory agencies and policymakers, are re-examining their approaches to pain management and how it’s taught.

Comprehensive pain management is much more complex than just writing a prescription. The plan can include opioids when necessary. But the comprehensive approach also involves listening to patients, thinking creatively about treatment options, and working with doctors focused on different disciplines.

Read the full transcript of this segment below:

JOSEPH ZEBLEY: Along in here, Any pain?

LYNN LEVINE: No, but I did take my medicine this morning.

CHRISTOPHER BOOKER: Lynn Levine is one of tens of millions of Americans diagnosed with chronic pain. After numerous surgeries for a range of health problems, Levine has taken opioid painkillers for the last seven years.

LYNN LEVINE: One medicine, morphine, in the morning. And I take an oxycodone at around noon or 1 o’clock. And then I take a morphine late in the evening. They’re long acting.

CHRISTOPHER BOOKER: Where would you be, do you think, without the opioids?

LYNN LEVINE: I think I would be laying in a bed most of the time.

CHRISTOPHER BOOKER: Levine’s doctor, Joseph Zebley, has been treating patients with cancer and chronic pain since the 1980’s. He and Levine recognize the risk of addiction in taking these potent drugs.

CHRISTOPHER BOOKER: You have a very healthy fear of just how this opioid intake can get out of hand.

LYNN LEVINE: It can.

CHRISTOPHER BOOKER: Why?

LYNN LEVINE: It can, because I know it can, because I’ve known lots of people who take it unnecessarily and take it for the high they supposedly get off of it.  And I don’t want to be in that position.

CHRISTOPHER BOOKER: As the number of U-S prescriptions for opioids doubled over a 15 year period from 105 million in 1998 to 207 million in 2013, the number of fatal overdoses from the drugs soared almost fivefold, from four thousand deaths a year in 1999 to nearly nineteen thousand in 2014. That includes people who illicitly used prescription opioids and those who overdosed on pills prescribed for them.

As recently as the early 1990’s, doctors were criticized for not prescribing enough painkillers, according to David Thomas, a doctor who works for the National Institute of Drug Abuse, known as NIDA.

DAVID THOMAS: Back then, there was a thing called opioid-phobia. A lot of healthcare professionals did not want to prescribe opiates at all, because they thought you give the slightest amount, you turn your patients into addicts. And so even people with stage four cancer weren’t being given opiates, they were left to suffer.

CHRISTOPHER BOOKER: Dr. Zebley says prescribing opioids wasn’t a treatment option he even considered for chronic pain when he graduated from the University of Maryland School of Medicine 40 years ago.

JOSEPH ZEBLEY: Back then, if we wrote for even Tylenol with codeine you would have a precept, or someone, looking over your shoulder and wondering why you were using a narcotic.

DAVID THOMAS: I think there was a number of well meaning health care providers that said, ‘This is wrong. We have to take care of people in pain. And we have the means, we have opiates.’ Instead of just using them to some degree to help people, they were starting to be used just as a replacement for comprehensive pain treatment.

JOSEPH ZEBLEY: And then there was an entire movement and I have colleagues who were in pain medicine who were involved in this movement, who said that we had an unrecognized epidemic of pain in America.

CHRISTOPHER BOOKER: As the approach to treating pain evolved, pharmaceutical companies touted studies saying painkillers carried little risk of addiction.

JOSEPH ZEBLEY: I think I, like many others, were fooled into at least partially believing that and starting to write prescriptions more liberally.

CHRISTOPHER BOOKER: How much responsibility do the doctors have in our opioid epidemic?

JOSEPH ZEBLEY: I think we all share some responsibility. But I would put a lot more and this may be controversial, on the pharmaceutical industry. I won’t name the names of certain companies but they were in my office 15, 20 years ago promoting long-acting narcotics with articles in their defense saying that these were less addicting.

CHRISTOPHER BOOKER: In the late 1990’s, Purdue Pharma, the maker of Oxycontin, which earned billions of dollars in revenue for the company, promoted the painkiller as having a low risk for addiction. But in 2007 the company admitted those claims were fraudulent and paid 600 million dollars in fines.

Since 2010, Purdue says, it has “reformulated Oxycontin with abuse-deterrent properties.” And it now refers physicians to new guidelines for opioid-prescribing from the Centers for Disease Control.

When releasing the guidelines in March, director Tom Frieden of the CDC stated: “The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits.”

LYNN LEVINE: I wouldn’t be able to stop ’em right away. That’s for sure.  Because I’m physically addicted, not, you know, not addicted where I take more than the dose that they order. But I’m physically dependent on them. And that would mean a lot to me if they were to just, you know, stop the doses all of the sudden.

JOSEPH ZEBLEY: There’s a certain amount of anger on the part of physicians who feel trapped. We have a large cohort now of patients who are taking these medications long term and on the other hand we’re being told, ‘Well, you guys are at fault because you’re writing all these opioids.’  Well, what are we to do?

CHRISTOPHER BOOKER: One answer to that question has been for medical schools to reexamine how their students are taught to treat pain.

A 2011 study found that during four years of training, a typical U-S medical student spends only nine hours learning about pain.

DAVID THOMAS: That’s, like, one long day at work. The amount of opioids that we’re prescribing is way too much and the amount of education that the average prescriber gets is way too little and that’s a prescription for disaster.

ANTJE BARREVELD: The challenge is there’s only so much time in the day and medical students have to learn about lots of things.

ANTJE BARREVELD: You doing OK?

CHRISTOPHER BOOKER: Dr. Antje Barreveld is a pain specialist and assistant professor at Tufts University School of Medicine outside Boston. Barreveld says that Tufts currently has no formalized program on pain. Right now she teaches roughly fifty students a year about pain for one hour.

ANTJE BARREVELD: She told the nurse that she ran out of oxycodone.

ANTJE BARREVELD: I think that a lot of the students still feel that managing pain is very mysterious. They still just don’t have a real handle on the basics of it.

CHRISTOPHER BOOKER: So Barreveld has developed a new pain education class as part of a program by NIDA and the National Institutes of Health. They’re making 50 to 100 interactive pain patient case studies accessible online, so other medical schools can use them too.

This case study shows a re-enactment of Barreveld assessing a patient with a history of chronic pain and substance abuse.

The students then meet with her to think creatively about treatment options, including physical and behavioral therapies as well as opioids, if appropriate, at low doses, and with caution.

ANTJE BARREVELD: Can you get “hooked” on buprenorphine? Absolutely. It’s an opioid.

CHRISTOPHER BOOKER: Tufts third year medical student Olivia Pezulo took Barreveld’s class and says it was the most comprehensive pain training she’s had.

OLIVIA PEZULO: You have a lot of exposure to patients and pain, but you don’t get the exposure to the treatment side of it.

CHRISTOPHER BOOKER: So then what was different here?

OLIVIA PEZULO: First of all just addressing this is problem, this is real. And then coming up with multiple options and some are options I’ve never seen before and not really heard of before.

ANTJE BARREVELD: We get to have perspectives from different disciplines. A nurse treats pain very differently from a doctor or a dentist or a pharmacist. But we all together can come up with some excellent strategies that complement each other.

ANTJE BARREVELD: It’s real. Your pain is real. But you’ve made so much progress. This is why I have tissue boxes here.

ANTJE BARREVELD: Pain isn’t necessarily that simple. And there aren’t easy answers to treating it. And it often takes a special kind of person to take the time to really listen to the patient. So modeling that for students, of course, is the ultimate goal.

CHRISTOPHER BOOKER: What more do you think medical schools should be doing?

ANTJE BARREVELD: So finally someone is recognizing that this is important. I’m hoping that it’s not just gonna be an opioid-centric education. I think this needs to be about human beings as a whole and the human that suffers.

CHRISTOPHER BOOKER: This holistic approach is something the University of Maryland School of Medicine is trying with its month long elective dedicated to alternatives to medication for treating pain. The techniques range from chiropractic methods to guided imagery techniques that incorporate meditation and even Tai Chi. Fourth year medical student Kevin O’Malley took the class.

KEVIN O’MALLEY: After taking this rotation, I feel much more comfortable and prepared for treating chronic pain in patients because I’ve been exposed to so many different therapies. I think it can be easy to think, “Well, you know, someone’s in pain, they experience it like anyone else does. And it’s more complicated than that.

CHRISTOPHER BOOKER: O’Malley plans to become a family doctor, just like Maryland Alumnus Joseph Zebley. Seasoned physicians like him are taking steps to update their training. Maryland is one of at least 20 states where doctors are required to take a class in pain management, opioid prescribing, or substance abuse in order to be relicensed.

SPEAKER: Don’t ever think you know your patient even if they show up once a week for something. You don’t.

JOSEPH ZEBLEY: I think it’s a reasonable first step. But it’s nowhere near sufficient to really have doctors slow down the use of opioids.

CHRISTOPHER BOOKER: At least 12 twelve states also require doctors to check databases listing who has been prescribed opioid painkillers before issuing the first opioid prescription to a patient. But none regularly check to see if prescribers are actually using the database.

JOSEPH ZEBLEY: Has anyone talked to you about weaning….

CHRISTOPHER BOOKER: Zebley still faces the challenge of managing opioid dependent patients like Lynn Levine. He says he’s vigilant in looking for signs of abuse and avoids prescribing opioids unless it’s absolutely necessary.

CHRISTOPHER BOOKER: How hard is it for you, in that position, and for doctors to change this, being like what I was taught was wrong?

JOSEPH ZEBLEY: Well, first you have to have some humility. That’s hard right there. And then one has to change. But we’ve changed how we use antibiotics.  We’ve changed what we do for high blood pressure. So if you have science that backs you up then you change. It may be difficult.

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