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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.