For my family medicine rotation, I was placed in a small practice on the outskirts of New Orleans. With eager naiveté, I envisioned seeing patients teeming with variety in their presentations. What I encountered instead was an alternating list of two chief complaints: “chronic pain” and “Suboxone refill” (replenishment of a drug to treat opioid withdrawal). I found myself at once immersed and adrift in the intricate and seemingly ironic management of both chronic pain and opioid dependence. Despite my disorientation, my response when I was asked if I was ready for the next patient was always “Sure.”
Part of my job involved checking the clinic’s prescription-monitoring program, a state-run database regarding the dispensation of federally controlled substances and potentially addictive or abusable drugs. In doing so, I often felt like a private investigator disguised in a white coat. And when questioning patients about their symptoms and the legitimacy of their pain, I wavered between feeling guilty and justified. I felt like part of a pendulum swinging between help and harm, with the steadying forces of pain education and the patient’s illness narrative being underutilized. I wanted to see pain and addiction as a disease state, a widespread public health burden, not merely a symptom. I wanted to become a thoughtful prescriber. I knew there was much more to know.
I now recognize that my frustrations were rooted in my lack of medical education on this topic. While I feel comfortable with first-line biologic treatments for medical diseases with an incidence of one in a million, I remain lost in the presence of pain, as pervasive as it is. It is both foreign and familiar. The many readily available tables showing the mechanisms of analgesia and the side effects of pain medications have failed me by not translating data into clinical competency. Some have called this a “disastrous omission” in medical education. It is.
While the burden of patients living with pain is intuitive, the management of pain is not. I know I’m not alone in these feelings, yet I am hopeful that pain management will find a voice in medical education. Let’s talk about it; let’s learn. Not only from one another, but from our patients, too.
Oyster Bay Cove, New York