Approaches to Pain Management


Four experts delve into pain management and how opioid abuse factors into their decision-making.

Matthew A. Torrington, MD: How has the opioid overdose epidemic changed how clinicians manage pain? It’s incredibly ironic that as physicians have clamped down on furnishing patients with opioids for pain, because of the state of our mantra and our position from a legislative and an administrative position medically, overdose deaths have gone up and continue to go up.

Bill H. McCarberg, MD: Absolutely. Your question is about what has happened with clinicians who manage pain. I’m a pain expert, but all my primary care colleagues are very hesitant to give out any opioids, regardless of the pain condition. In the last 4 years, I’ve been doing hospice and palliative care, and I’ve noticed more reluctance and that these are people that are dying. They have a cancer diagnosis. They’re dying, but they’re cared for by caregivers who are the risk population. They’re the ones who are stealing Grandma’s oxycodone and using it illegally. That population is scaring us in hospice and palliative care, so we want to be very careful about the amount we give and the strength we give, not because of the patient but because of the caregiver, who we don’t have very much control over. In my entire practice, there’s been very strong reluctance to use medications for pain.

Thomas R. Kosten, MD: I’ve been involved with several cases of primary care physicians prosecuted by the local police and the DEA [US Drug Enforcement Administration] around illicitly prescribing them—they’re calling them pain mills—But these are primary care doctors, and less than 10% of their practice involves prescribing pain medications. They’re prescribing pain medications at quite modest doses. They’re often taking on patients who’ve been prescribed much higher doses by other doctors, who are then put out of business. These are middle-aged guys. It’s not as if they’re demented or something. They know exactly what they’re doing, but they’re being prosecuted for becoming pain mills when there’s nothing. They have notes in the charts and things, so there’s an extreme reaction. This may be more peculiar in states such as Texas, where I am, than it is in others. Texas and Florida have been overwhelmed with these pill mills. That’s spread to prosecuting doctors who’ve been willing to take on these difficult pain management cases that were abandoned. They were addicted 10 years ago, but they’re still addicted.

Matthew A. Torrington, MD: They’re still in pain. A lot of these patients have a real pain generator, and it becomes incredibly difficult to serve the needs of the patient to stay out of trouble and to figure out the right thing for these patients who are suffering.

This transcript has been edited for clarity.

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