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Baker’s opioid plan gets it only half right

André da Loba for The Boston Globe

Governor Baker’s plan to increase opioid education, which he announced on Nov. 9 with the deans of the state’s four medical schools, gets it only half right.

It's wonderful to teach future doctors how to prescribe opioids safely to reduce abuse and addiction. But the United States is actually caught in the middle of two colliding epidemics, not just one: the well-publicized problem of opioid abuse, and the under-publicized epidemic of chronic pain, which affects 100 million American adults, according to the Institute of Medicine.

Unfortunately, medical schools not only fail to teach students how to prescribe opioids, they also do an abysmal job of teaching about chronic pain itself. Chronic pain is not just acute pain that doesn't go away after three to six months. It is now known to be a disease of the nervous system in its own right, and not just a symptom of something else. It is the main reason Americans go on disability, and a leading reason people go to doctors.

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Yet during four years of medical school, American medical students get a median of only nine hours of pain education, according to a 2011 study by Johns Hopkins. Even veterinary students get more — 87 hours, other research shows.

In the laboratory, pain researchers have discovered a lot about chronic pain: how the nervous system transforms itself as acute pain shifts to chronic pain; how microglial cells derived from the immune system help with this transformation; how a handful of genes play a major role in a person's susceptibility to chronic pain; how hormones such as testosterone and estrogen influence pain sensitivity.

But doctors on the front lines don't know this because medical schools don't teach it.

Doctors themselves are fully aware of how ill-prepared they are to help people in chronic pain. One survey by Harvard Medical School researchers found that half of doctors in primary care positions felt only "somewhat prepared" to counsel patients on pain management. Because they learn so little about pain in medical school, few young doctors have any desire to become pain medicine specialists. When professors at one medical school asked graduating medical students what they would do when faced by a pain patient, one student spoke for many: "Run!"

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Indeed, chronic pain appears to be an important driver of the rising suicide rate among white, middle-aged Americans, according to a study published last week by Princeton economists.

There are no hard data on how many people with chronic pain die by suicide every year. But it is known that people in chronic pain are significantly more likely than those not in pain to commit suicide. Given that there are about 41,000 suicides every year, according to the National Center for Health Statistics, this suggests by inference that more than 20,000 Americans a year with chronic pain kill themselves. That would be more than the government's figure of 16,235 deaths per year involving prescription opioids.

The other tragedy in all this is that because of time and reimbursement pressures, doctors on the front lines get only a few minutes with each patient. That's not enough time to address the other issues in a person's life that may be adding to the distress of chronic pain. Nor enough time to advise about nondrug treatments such as acupuncture, massage, exercise, meditation, or alternatives such as marijuana.

The governor's plan pays lip service to teaching medical students how to evaluate a patient's pain. But lip service is not enough. The state government has declared that substance use disorder is a "chronic, progressive, relapsing disease."

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So is chronic pain.


Judy Foreman is the Globe's former Health Sense columnist and the author of "A Nation in Pain: Healing Our Biggest Health Problem."