Reforming pain management education for the next generation of physicians

After seven years in private practice, Rachel Franklin, MD, returned to where she finished her residency in family medicine and saw a need to improve the way the family medicine center treated its pain patients. She started from the ground up. Taking on the role of medical director at the University of Oklahoma College of Medicine’s Family Medicine Center, she “wanted to start over with the way we were teaching pain management as well as the clinic workflow so that we could actually provide an objectively assessed, mechanism-based management program for chronic pain.”

Dr. Franklin and her colleagues created a peer-reviewed, structured curriculum that focused on improving patient outcomes. She implemented workflows where patients complete a self-assessment at each visit which includes their medical history, in addition to an opiate risk assessment at their initial visit. Their opioid risk is documented—as are any indications of misuse, non-adherence or diversion of their medication—and patients are then monitored regularly through standardized assessment tools. The clinic also established standard refill expectations, which “greatly improved the whole clinic environment,” Dr. Franklin said. “Patients no longer walk in unannounced expecting a refill. We have built in structured expectations and we have seen great results for the patients who have stayed with us.”

The objective assessment tools and mechanism-based treatment program are designed to try to help physicians avoid initiating opioids in an effort to balance patient safety with effective pain care.

“With the medical students, we talk about the socio-political aspects of pain management, we talk about the experience of pain, and we talk about a mechanism-based approach to pain. We discuss many different questions, such as: What is neurologic pain? What is functional pain? What is musculoskeletal pain? What is affective pain? And then what can we do within those mechanisms? Everything from acupuncture, physical therapy and biofeedback to complementary medications like magnesium and B-vitamins to the non-opiate medications.”

Despite the progress they have seen locally, Dr. Franklin says there are still big changes that need to be made so that patients nationwide can get better, more multidisciplinary treatment: “Until you can give me a policy by which physical therapy, occupational therapy, massage therapy, acupuncture, biofeedback and behavioral health are as cheap as a five-dollar prescription for [an opioid] each month, I’m going to have problems.”

Dr. Franklin also understands that legislative fixes may not always be as helpful as intended. “I teach medical students about the swinging of the political pendulum and how it influences practice in ways that aren’t necessarily evidence-based. What we’ve tried to do with our curricular and advocacy efforts is to balance that pendulum, so that it doesn’t swing so far from side to side.”

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