“We learn from history that we learn nothing from history.” —George Bernard Shaw (1856-1950)

Editor-In-Chief,
Chester “Trip” Buckenmaier III, MD,
COL (ret.), MC, USA

This past week, I attended the Uniformed Services Academy of Family Physicians (USAFP) annual meeting in Seattle. I was there representing the Defense and Veterans Center for Integrative Pain Management (DVCIPM.org) as the organization director on behest of Maj. Gen. Jeffery Clark the current director, Operations Directorate Defense Health Agency (DHA), and a family physician. Maj. Gen. Clark has made pain a priority topic for DHA and wanted DVCIPM, the Center of Excellence for Pain in the DOD, to be on hand exchanging ideas and leveraging our pain management products with primary care docs.

Since most pain in healthcare is first managed in the primary care environment, this effort not only makes sense but probably is long overdue. Perhaps that is why Maj. Gen. Clark is a general.

The meeting went well, and we had the opportunity to expose federal primary care physicians from across the nation to new ways of thinking about and managing pain in their patients. For the pain discussion, the highlight of the meeting was an afternoon session on primary care pain management co-chaired by Maj. Gen. Clark and Dr. Diane Flynn, who serves as the Madigan Army Medical Center primary care pain management adviser. This session was a refreshing exchange about new ideas concerning nonpharmacologic approaches to managing pain.

Frustratingly, despite general agreement that integrative medicine approaches to pain were critically needed, there was considerable discussion about the overall lack of these services, because many treatment approaches such as acupuncture or massage are not covered by TRICARE. This discussion was particularly disturbing to me because of what I had observed on my short walk to the meeting conference center that morning.

Our DVCIPM team was staying at a hotel near the USAFP meeting. The walk to the meeting venue took us past McGraw Square in downtown Seattle. As we passed the square, we were shocked to see drug use paraphernalia casually scattered on a stone bench. A colleague took a cellphone photograph of the appalling scene (Figure 1). To be clear, this is not an indictment of the fine city of Seattle which I have always enjoyed visiting. Based on the growing death rate from illicit opioid use, I am sure the scene I witnessed is a common sight in many American cities today. What struck me was the juxtaposition of this public display of the tragedy of addiction being played out next to a conference filled with physicians struggling with the challenges of managing pain with anything other than pills. Sadly, with the exception of our interest, the local Seattle passersby barely even noticed the occurrence as extraordinary.

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Comments (4)

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  1. Maria Romanas, MD, PhD says:

    I am heartened at your willingness to consider alternative therapies for pain. I am a pathologist. One day a week I am on my feet all day grossing in my specimens. By the end of the day, my back really hurts. Deep tissue massage has been a lifesaver for me and has also kept sciatica at bay. I cannot recommend it enough.

  2. Susan Reece says:

    Being in pain is so debilitating; any choice but drugs that are mind altering should be readily available to all veterans. Occupational health should also should educate staff on alternatives to medications as well; especially since there is a delay in getting a response when one is in back pain with poor chair support or improper computer station.

  3. Ron Malachowsky,PA-C says:

    I couldn’t agree more with your timely letter. For far too long our insurance companies have been able to operate in the “business as usual” mode and the public, let alone the medical community, has not held their feet to the fire, has not come out in a strong enough, collective voice to their politicians to implement changes to “the system” which would provide coverage for non-medicinal alternative strategies to managing pain. As one who has personally availed themselves, often at their own expense, to such modalities as chiropractics, acupuncture, & massage I can attest to their needing to be in the day to day bag of tricks practitioners can call upon to better manage their patients’ pain.

    Sincerely,
    Ron Malachowsky

  4. Mark McConnell, MD says:

    Thank you for reminding us to “learn from history”.

    The “history” I suggest we “learn from” is that the “experts” got us into a dilemma in the early 1990’s by quoting one paragraph from Porter and Jick in the NEJM that there was no limit to the safe dosing of opioids. This comment pertained to inpatients and not to the many-fold more outpatients. We in primary care knew this was flawed logic and have always wanted “interdisciplinary” means of helping patients. But I suggest that we be honest and say “there are few other specialists that are really available to help us”.

    The history lesson to be learned is that the pendulum swings: from the “experts” in the 1990’s saying “primary care doesn’t address pain” to the new lack-of-historical-context “drugs are dangerous” approach.
    May we start by eliminating using the word “pain”?
    May we return to what we were taught in medical school that “pain” is a symptom: and not a diagnosis?

    Unless we truly “learn from history” we will keep treating “pain” as a diagnosis rather than recognizing it as a SYMPTOM and delving into the root causes. Many of the “pain” symptoms we encounter are symptoms of underlying mental illness. A smaller proportion are actual somatic issues (my experience is that these are 10% or less…and those 10% percent are the elderly who could reasonably use one or two hyrorocodone at night for their non-operable osteoarthritis).
    Now the “experts” are not only telling us not to use opioids, but they talk of “pain clinics” which simply are not available for the vast majority in rural America. Yes, there are “injection clinics” which profit highly…but these are not true comprehensive “Pain Clinics”

    Are we willing to be honest?
    1. Might we expect a public and open apology to prescribers and patients about the nefarious efforts of the 1990’s?
    2. Might we cancel the onerous “laws” by government to now restrict opioids?
    3. Might we realize that the requirements for giving a simple low-dose opioid for elders requires a minimum of 5-15 minutes…every 30 days…in order to give poor elderly victims a simple hydrocodone once or twice per day. (after hydrocodone went from C4 to C2 in 2014)
    4. Might we ask The Dept of Defense to refrain from starting 20 year olds on narcotics?
    5. Might we reduce the rhetoric to PC doctors and simply let us practice medicine?

    Your article does not seem to suggest that we have “learned from history”: it only suggests that your advice will repeat the errors that history has taught us. We would propose a stoppage of the pendulum from swinging from “everyone should get narcotics” to “no one should get narcotics” and simply allow and encourage primary care doctors to partner with their patients on a PATIENT chosen path. ALL of our medications have RISK: why treat opioids differently? If we don’t know the answer to that question, we doubt that we are aware of the practical realities of full-time, front-line patient care.

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