Robert Rust, M.D.: Nuanced approach is needed for pain care

A recent article in The Spokesman-Review seems to blame physicians for overprescribing medication (“Confronting the consequences,” July 28), in light of new CDC guidelines published in May of this year, attempting to clarify the initial guidelines published in 2015 and apologizing for any confusion over the guidelines initially published, stating that they really did not mean for chronic pain patients who were stable and not having addiction issues to be forcibly weaned off their medication. Not only did that happen to most pain patients, but many of the new docs in training are refusing to manage patients in pain AT ALL because of fears of being censured by the Drug Enforcement Administration. That might be hard to believe, but it is happening.

The article does not explain the difference between opiates (medications and illicits derived from poppy plants) and opioids (synthetic medications like methadone, buprenorphine, fentanyl). The first two are used to treat Opioid Use Disorder (addiction). Furthermore, because doctors are treating pain patients with smaller doses of less-effective pills, but higher numbers of pills that do not reflect the reduction of dose size, the claims that we are using more and more numbers are not only misleading, but do not reflect that both common opioids increasingly used for the treatment of opioid addiction are included in these numbers, further misleading your readers.

I am pleased to report that the American Medical Association and American Academy of Family Physicians are listening to many groups of physicians complaining about the misleading of physicians and the public, including your readers. Efforts are ongoing to get the U.S. Congress to rescind the initial CDC guidelines and allow patients to be treated appropriately by their providers, doctors and mid-levels.

You are providing your readers information about the multidisciplinary approach to pain. Congratulations. If their pain can be controlled with these non-opioid measures, that is great. Unfortunately, that is not the case for many patients. I was a board certified family doctor from 1974-2014. Just like Dr. Clayton Kersting explained, we were not educated on how to screen patients for addiction and were prompted to treat that fifth vital sign aggressively. The teaching docs were right. We were too conservative and treated patients inadequately and that needed to be done, but as usual the pendulum, after swinging too far on the overtreatment side, now has swung too far back again to undertreatment again.

The final problem was that there were, until 2002, no safe and effective alternatives to opiates until buprenorphine (Subutex, Suboxone and years later Butrans, Belbuca, Bunivail and generic versions). What! Why weren’t they used for pain? Well they were primarily advertised for addiction and most primary care docs didn’t want addicts in their practices. Initially, only the IV prep was approved for pain, the others were used off-label successfully; later versions of the same basic drug were approved for pain. Your primary care provider can still use them for pain without the special certificate and training for addiction, but they really didn’t want to, so most didn’t take the training and still haven’t, even when the American Academy of Family Physicians says it is the right thing to do for your patients.

Which medication would you rather have for yourself and your family? A Schedule III opioid without significant respiratory depression that is very effective when dosed properly like buprenorphine and has killed only a single adult patient (Invidior) when used alone without other sedating medication, and not in patients with brain damage, or accidental overdose in kids? Or do you prefer powerful drugs that depress respiration and kill more often than auto accidents? Richard Lawhern’s website will scientifically explain why those deaths are primarily due to IV drug abusers, often using a mix with fentanyl or its cogeners, not your primary care provider’s reckless judgment, as suggested by the article.

Robert Rust, M.D., ABAM, FASAM, ABFM (emeritus)

Sandpoint