Editor's Memo
by Forest A. Tennant, MD, DrPH
 Throughout the life of this
publication, we have focused on the procedures, pharmaceuticals, and modalities that are
at the disposal of the physician who actively treat pain patients. We did not address
which particular specialty best prepares a physician for this role and it is certainly
true that more than a few have taken it on. However, there is currently no mechanism for a
primary care physician to become board certified in pain medicine.
At issue today is whether primary care physicians should prescribe long acting opioids
to ambulatory patients. Bringing this issue to the fore has been the Oxycontin crisis and
the high profile arrests and disciplinary action taken against some primary care
physicians. The claim has been that primary care physicians had been carelessly and
incompetently prescribing long acting opioids. There is little question that some
well-meaning primary care doctors have prescribed long acting opioids that have led to
abuse, diversion, and even deaths.
Two glaring facts stand out. One is that as many as 1 to 3% of our U.S. population of
about 300 million persons may require long acting opioids, yet less than 4,000 doctors
nationwide are certified pain specialists by the American Academy of Pain Medicine.
Obviously, there are not enough certified pain specialists to treat the massive need.
Further, many certified pain specialists do not wish to treat — or lack the special
interventionalist skills needed to effectively attend to — ambulatory intractable
pain patients.
All this adds up to the obvious conclusion that at least some primary care physicians
must prescribe long acting Schedule II opioids to meet the legitimate needs of the pain
patient population. The question is not whether the primary physician should prescribe
long-acting Schedule II opioids, but how we identify, train, and encourage primary care
doctors to take on this role — lest the epidemic of under-treatment persists.
However, current barriers to enlist primary care doctors in severe pain treatment is
almost insurmountable. As one primary MD recently told this editor, “I’d have to
have my head examined. Who need all the risks, lawsuits, and disciplinary action?”
So where do we go from here? We have some leads. There are some recent actions to
enlist and recruit primary care doctors. Recent efforts include those by Alpharma, the
company that markets the potent, long-acting morphine product, Kadian«. They have
recognized that the widespread distribution of severe pain cases in the country will
require a long-acting, potent morphine formulation that cannot be effectively serviced by
the limited number of pain specialists. Alpharma recently presented data and tutorial
material at the American Academy of Family Practice Annual Meeting held in Orlando.
Studies by Alpharma show that primary care physicians, with education and guidance, can
safely and effectively prescribe a long-acting morphine preparation in a community
setting.
We also wish to commend the certification given to primary care doctors by the American
Academy of Pain Management. Although not equivalent to the board certification offered by
the American Academy of Pain Medicine, this certification is open to primary care doctors
who wish to treat pain and wish to avail themselves of self-directed, post-graduate
training endeavors.
It’s time government agencies, including medical boards, realize that the US
population isn’t getting any younger or experiencing less pain, and that millions of
Americans need Schedule II, long-acting opioids. They should not berate primary physicians
who treat pain but, instead, join the efforts to identify, encourage, and train primary
care doctors to meet the needs of Everywhere, America and stop the epidemic of
under-treatment. It seems obvious to us that all parties should either support — or
develop — an alternative certification model currently offered by the American
Academy of Pain Management. This issue is far too formidable to ignore.
— Forest A. Tennant, MD, DrPH
Editor in Chief
— Jan/Feb 2005
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