Insufficient knowledge among physicians about pain assessment and management

Critics of medical education in the area of pain - its causes, assessment, and treatment - suggest that the typical medical school curriculum seems almost purpo sely designed to keep physicians in the dark about pain. In a 1989 interview, John J Bonica, generally regarded as the founder of the movement toward specialized pain clinics, observed, "No medical school has a pain curriculum.''33 Over 15 years earlier, a study of hospital inpatients revealed significant undertreatment of pain based in part on marked knowledge deficits on the part of physicians with regard to effective dose range, duration of action, and risks of addiction for narcotic analgesics.14 At the conclusion of the study, the authors called for a major educational initiative, beginning in medical school, to improve the knowledge and skills of physicians in the use of narcotic analgesics for the management of pain. Interestingly, in addition to basic medical information, the authors suggested that any program of instruction must take into account the fact that for many physicians these drugs "have a special emotional significance that interferes with their rational use.'' The term which has been coined to describe this phenomenon is "opiopho-bia.''34 Like other, more generally recognized phobias, opiophobia cannot be cured or even effectively controlled by classroom education about the groundless nature of the fears. It is a behavior that is modelled and reinforced throughout all levels of medical education, from student clerkships to internship and residency.

The pharmacologist who coined the term "opiopho-bia'' indicates that, after closely observing the opioid analgesic prescribing patterns of physicians in the United States, it would be tempting, but technically incorrect, to declare that "American physicians know nothing of the treatment of severe pain with narcotic opioids.'' They have learned well, as they progressed through their medical education, the prescribing patterns that are customary. Those patterns, however, are inconsistent with the best current medical knowledge. Indeed, they suggest that the patterns and practices that are at the root of undertreated pain have nothing to do with medical science whatsoever. For example, the belief that chronic pain patients managed with opioids are likely to become addicted (as opposed to physiologically dependent) runs directly counter to the best clinical data, which indicate that the risk of iatrogenic addiction for pain patients is less than 0.01 percent.35 Similarly, the widespread fear of severe, perhaps even fatal, episodes of respiratory depression runs directly counter to numerous reports in the medical literature. Although many of these reports pertain to cancer patients, the salient point made therein is that it is only the opioid-naive patient who is at serious risk of respiratory depression.36 A patient with moderate to severe chronic pain, regardless of whether it is caused by malignancy, whose analgesic level has been titrated upward appropriately, is not at serious risk.

It would be a mistake, however, to assume that opio-phobia is entirely an American phenomenon, one secondary to such unique aspects of American culture and social history as the puritan heritage, the "noble" experiment of prohibition, or the contemporary "war on drugs.'' Restrictive prescribing laws are common in many European countries, both reflecting and sustaining an international opiophobia among healthcare professionals as well as patients.20 In 2004, the International Narcotics Control Board Annual Report identified three reasons for the continued inadequate use of opioid analgesics:

1. unnecessarily strict rules and regulations governing their use;

2. negative perceptions about controlled drugs among medical professionals and patients; and

3. lack of economic means and resources.37

The role played by overly strict rules and regulations will be considered below under Fear of regulatory scrutiny of opioid-prescribing practices. The negative perception of opioids is one that appears to be not merely socio-cultural in nature, encompassing both lay persons and healthcare professionals, but also linguistic. A recent European white paper offered several vivid examples. In Austria, narcotics are referred to as Suchtmittel, the literal translation of which is "the means to make you addicted.'' In Germany, narcotics are referred to as Betaubungsmittle, or the means to "knock you out.''38

It is extremely difficult to measure the extent to which opiophobia is a product of overzealous regulatory measures (such as a declared "war on drugs'' in the United States) to deter and detect drug diversion rather than the persistence of myths and misinformation about the risks and benefits of opioid analgesics. Nevertheless, it is a lamentable fact that the rhetoric and modus operandi of the regulators in their efforts to prevent or punish the diversion of or trafficking in narcotics has made physicians conscripts and pain patients noncombatant casualties, and has inflicted grave collateral damage on one of medicine's core values - the duty to relieve suffering. Recently published follow-up studies strongly suggest that state medical licencing board members, who play a pivotal role in the regulation of physician prescribing of opioid analgesics, have been particularly resistant to reeducation on such issues as the nature of addiction and the appropriateness of opioids in the management of some patients with chronic nonmalignant pain.39 We will consider this issue below under Fear of regulatory scrutiny of opioid-prescribing practices.

In concluding our analysis of this particular barrier to effective pain management, I wish to introduce a concept which I characterize as "the culpability of cultivated ignorance.'' As we have seen in this brief survey, it has been known and identified as a problem for decades that medical school and residency training program curricula are woefully inadequate with regard to the assessment and management of all types of pain. Yet these institutions have failed or refused to reform themselves. It surely cannot be because pain has not been shown to be a pervasive problem frequently encountered by most physicians in their practice. The continuing absence of a significant pain component in medical education and training is indefensible, and the calling to account of these institutions by society for the persistence of such curri-cular deficits and their negative impact on patient care is long overdue.

A pain curriculum in medical school that is worth the effort it would take to implement would need to be comprehensive. It must begin in the lecture hall and continue through the role modelling and mentoring by a faculty of senior medical students, interns, and residents. The custom and practice in the institutions where young physicians are enculturated must be consistently based on the latest scientific knowledge and outcome studies of pain treatment modalities, something that the prevailing practice of physicians in most countries presently does not provide.

What is equally troublesome, however, from an ethical standpoint, is the continuing reliance by practicing physicians upon these curricular deficits as an excuse for why they fail to possess state-of-the-art knowledge and skill in pain assessment and management. While deficiencies in their professional education and training may provide an explanation for substandard care of patients with pain, they do not constitute an excuse. Entering a profession entails the acceptance of a responsibility to engage in lifelong learning and the continuing development and refinement of the knowledge and skills essential to the competent practice of that profession. The law can and will hold people responsible not only for applying their knowledge and skills in a prudent manner, but also for a failure to possess the knowledge and skills necessary to adequately engage in their profession or calling.

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