When was the last time you heard a colleague express genuine excitement about learning anything new regarding pain therapeutics? If a game-changer were to emerge, would it matter if no one is still playing the game? For people with pain it’s the bottom of the ninth, two outs, two strikes, bases loaded and the team is down by 3.
The onslaught of media negativity and their sensationalism about the realities of pain management is daunting for patients and professionals alike. The cherry picking of data, the pseudoscientific shortcuts, the political bully pulpits to gain favor, the collective self-serving rhetoric is simply too much; getting to the point where even those warriors committed to answering back to the dishonesty are exhausted from correcting the false portrayals. When lecture after lecture at major medical and pharmacy meetings are on “risk management” surrounding opioids or some semblance of that in the lecture tagline, the game is over. How can we remain passionate about attending meetings in which all anyone is expected to learn is how not to kill anyone? Most pain clinicians entered this field of study with a desire to apply themselves for the betterment of humanity and the relief of suffering. As each days passes, it seems that instead it’s about careful documentation and avoidance of liability.
Before readers begin assessing whether the authors of this post (a senior and junior clinician) are suicidal, please recognize that there is a certain degree of compassion fatigue that can come with this territory. Compassion fatigue has been defined as essentially a form of burnout common to those of us who actually care; it’s not simply the burnout of too long hours, too much stress, too little camaraderie, too much witnessing of pain and suffering – it’s all of those things but if you have thick enough skin and/or were born without the caring gene, you might be less susceptible.
One of the hallmarks of compassion fatigue or caregiver burnout is that it distances you from the source of the stress – either through numbing or avoidance – in this case the people you want to care for and the subject matter that reminds one of the stress. What is a very obviously vicious cycle then takes shape as you distance yourself from the very source of joy, hope and inspiration that led you to the pain clinic to begin with. The human richness could flea away with diminished hopes to learn and grow and rekindle passion for relieving pain and suffering.
We continue to demand ingenuity from the drug makers. Whether it is abuse deterrent products, new opioid innovations or non-opioids, is there enough enthusiasm for those who have been beaten into keeping a low profile to stand up and take notice. In the world of opioids, if there were a safer opioid product for the day, is their enough therapeutic wiggle room, backbone and commitment to recognize it as such or will the absence of evidence taken to be the evidence of absence cut off treatment so dramatically that it then drives more absence of evidence from this time forward?
If there were an efficacious opioid drug with less abuse and diversion potential; less potential for overdose due to a ceiling effect on CO2 accumulation; untapped possibilities for the relief of certain psychiatric comorbidities that frequently accompany pain; all of which could be used to help patients avoid traditional opioids, would it be used? That’s the million-dollar question! Let’s take a look at what’s available.
Three buprenorphine products are FDA-approved for pain and do in fact represent a safer alternative. These include the newest formulations indicated for chronic pain, Belbuca Buccal Film (12-hour dosage formulation) and Butrans Transdermal (7-day topical patch). Then there’s the oldest formulation, Buprenex Injection (generally for acute pain and institutional use). For an overview of all available buprenorphine dosage forms, see A Brief Review of Buprenorphine Products. Irrespective, the lack of pharmacological understanding of this drug is mindboggling as it seems always to be associated with opioid abuse or inaccurately likened to methadone. Those in the addiction community who are more familiar with buprenorphine’s clinical benefits have recognized its potential in their group of patients who have both pain and addiction but can sometimes sound almost too enthusiastic – of course the addiction community is having its day in the sun now, though, so they have not been robbed of their passion. And of note is that Subxone and rehabilitation clinics have turned millions of dollars in profits which might even incentivize certain anti-opioid zealots to spin the rhetoric of opioid overdoses out of control. Consider for example that annual NSAID-related deaths from gastrointestinal bleeds are about equal to that of prescription opioids – but alas, there is no black market, profitability from NSAID-rehab clinics, or sexy media initiatives to push that fact to the edge of a cliff. Nevertheless, we continue as a society unable to hold two thoughts in our heads, the suffering of the addict now that rules the day and the suffering of the pain patient has been relegated to a bottom dweller. Both pain and addiction are obviously of equal importance and it shouldn’t matter that the addiction community is resurgent and the pain community downtrodden.
Whether a young aspiring clinician or a more seasoned aficionado, we intend to remain in the game. Grand slam? Perhaps not. But, in this new residency year we will both take that chance and together swing for the fences even if we miss? If either of us gets called out looking with the bat on our shoulders, we’ll be back next time.
Is anyone out there still playing the game?
PLEASE comment and tell us if you’re still in the game, and if not, why not!
This post was collaboratively written with Dr. Erica Wegrzyn.
Erica Wegrzyn, B.A., B.S., PharmD is currently completing a PGY-2 Pain and Palliative Care residency at the Stratton VA Medical Center, Albany NY. Dr. Wegrzyn received her PharmD from Western New England University College of Pharmacy, Springfield MA and completed a PGY-1 residency at Maine General Medical Center, Augusta ME. Prior to completing her PharmD, Dr. Wegrzyn also received her bachelors’ degrees in Biochemistry and Music (trombone) from Ithaca College. Dr. Wegrzyn’s initial interest in pain management was sparked by her exposure to Dr. Fudin’s pain practice during her final academic year while completing an advanced practice rotation at the Stratton VA Medical Center. In her new role as a PGY2 Resident she has already had an intense few weeks with three pending publications and is looking forward to some busy clinics starting next week. Dr. Wegrzyn thrilled to return to the Albany area where she is will resume her roles as a volunteer firefighter with Selkirk Fire District and also with “Out of the Pits” pitbull rescue. Dr. Wegrzyn is pictured here with her therapy certified and Selkirk FD resident fire dog, Blue.