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“Pain is the great equalizer. It humbles us all,” says Dr. Brendan O’Donnell. A pain management specialist at Harborview Medical Center and current president of the Washington Academy of Pain Management (WAPM), he assists patients with chronic pain, administers anesthesia in the trauma center at Harborview and facilitates with acute postoperative/posttraumatic pain management. In those roles, O’Donnell can attest to the complexity of a practice that requires sifting through an arsenal of treatment options to find the right fit for an individual’s discomfort.
From patients with chronic back problems to those who need postoperative treatment, many find their way to a pain management specialist through a doctor referral or in the hospital as they’re recovering from trauma or surgery. Pain specialists use, among many other treatments, steroid injections, acupuncture, and opioids, a group of drugs that includes oxycodone and are the most widely prescribed class of medications in the United States.
They are also among the most widely abused and as such, are controversial among doctors. Increased deaths and hospitalizations due to opioid overdoses led the Washington State Legislature to pass Engrossed Substitute House Bill 2876, which went into effect in 2011 and includes some of the most restrictive pain management standards in the country: It directs medical boards to adopt rules for reviewing treatment—patients consult with a pain specialist once they reach a certain dose threshold before taking a higher dose—and to restrict opioid prescriptions for chronic pain (excluding end-of-life care).
Dr. Ray M. Baker, medical director of the EvergreenHealth Spine and Musculoskeletal Program, began shifting his pain management methods away from opioids long before the law took effect. Although those medications helped some of his patients, he was surprised by the many who did better without them. He notes that there are a variety of nonnarcotic alternatives available that are effective for chronic pain. For example, to treat localized pain, he may use injections of epidural steroids.
Patients who prefer to avoid pharmaceuticals entirely can look to naturopathic doctors for pain management. Naturopaths can provide lifestyle evaluations and natural treatments, such as supplements or acupuncture. Dr. Jamey Wallace, chief medical officer at the Bastyr Center for Natural Health, thinks that the law might lead more patients down this route. “It’s an opportunity to encourage patients to be thinking about other options,” she says.
There are a few reasons why doctors are cautious with opioids: Patients can build a tolerance to them if they are used for long-term treatment, O’Donnell says. In addition, higher doses can cause changes in the central nervous system that create more pain, sometimes irreversibly, says Dr. Charles Chabal, director of pain management at the EvergreenHealth Pain Management Center. Lastly, opioids are depressants, says Baker, and can increase the underlying depression in some chronic pain patients.
The legal restrictions do not apply to cancer, and doctors such as Dermot R. Fitzgibbon, M.D., an anesthesiologist at the University of Washington who manages both chronic and tumor- and treatment-related pain at Seattle Cancer Care Alliance, finds them necessary. He hasn’t seen his patients develop tolerances and only increases dosages for worsening tumor pain.
The opioids law has had an impact on how primary care doctors approach pain management—and if they’ll approach it at all. “More doctors [now] declare medication management for chronic pain as an area too specialized to do safely on the primary care level,” says addiction medicine specialist Dr. Michael Schiesser, who assists physicians at EvergreenHealth with pain management. Physicians who are willing to treat pain have found themselves with more patients, with some doctors increasing staff to accommodate the influx.
Overall, though, Schiesser and other doctors agree the law has more pros than cons. O’Donnell thinks Washington will serve as a model for other states, which can adopt or improve on the law. “The rest of the country can learn from our success or failure.” ✚