Healing the Hurt
How effective is the training health care providers receive in using opioid drugs in pain management?
A new study suggests not very.
UNM’s Joanna Katzman, MD, a recognized expert in teaching clinicians how to prescribe opioids responsibly, co-authored a paper published last month in the journal Pain Medicine that highlights significant deficiencies in the way prescribers are taught to manage pain.
And that, Katzman says, has likely contributed to the epidemic of prescription opioid abuse. “The whole idea of mandatory pain education has really been a hot topic nationally,” she says. “It’s timely right now just because of everything that’s been going on with unintentional opioid overdose.”
Katzman, executive medical director of the UNM Pain Center, and colleagues at Harvard, Stanford, Johns Hopkins, Tufts, the University of Pennsylvania, the University of Washington, the University of California, Davis, and the Cleveland Clinic came up with an ingenious way to gauge the training prescribers receive.
They decided to analyze the questions on the U.S. Medical Licensing Examination (USMLE) related to assessing and managing pain. They assumed that the exam accurately reflects the training medical students have received on the topic, Katzman says.
But first, the researchers had to convince the National Board of Medical Examiners, which administers the exam, to let them review the test questions.
“It took a while, but we got approval to go to Philadelphia to the examination site,” Katzman says. “It had to be high confidentiality, top secret – I couldn’t even tell my colleagues where I was going.”
Team members reviewed hundreds of questions on the exam, which is meant to test the competencies of physician candidates in various areas of medical practice.
“We wanted to see how many questions had the word ‘pain’ in them,” Katzman says. “If it just included the word ‘pain,’ but had nothing to do with pain, we threw it out. But if it was fully or partially related to pain, we evaluated it.”
Then they assigned the questions to different categories. “What we found is 88 percent of the questions were just about pain assessment,” Katzman says. That often amounts to little more than asking the patient to rate his or her pain on a scale of 1 to 10.
“A lot of the questions were about acute pain, instead of chronic pain,” she says. “There was not nearly enough on management of pain, especially in this crisis of people getting addicted to pain medicines.”
There were few questions regarding prescription safety, abuse or addiction, and little relating to chronic disease and co-morbid chronic pain – or chronic pain among military veterans, Katzman says. There were also few questions relating to end-of-life or cancer pain.
Pain is inherently subjective, Katzman points out. Perceptions of its intensity can vary widely from one person to the next – so trying to assign it a numerical value is an outmoded and misleading strategy.
“Pain does not have a number,” she says. “Pain is way too multi-factorial. It has psychological components, it has somatic components and there are cultural differences.” A better approach is to ask patients to assess how much – or how little – their pain interferes with daily tasks, Katzman says.
“Hopefully, this paper will inform the USMLE about making the examination more proportionate to what’s going on and what’s needed,” she says. “And maybe it will inform federal agencies about what they want to recommend to medical schools, nursing schools, pharmacy schools and dental schools about what’s important as well.”