By Desmond Colohan (guest opinion)
As I prepare to retire from clinical practice on September 30, 2014, leaving the province once again without a full-time pain specialist, I am very concerned that all our efforts of the past decade will have been for naught. We have been trying to recruit my replacement for the past two years with limited success. We did recruit an anesthesiologist with pain fellowship training to Summerside, but the majority of his time is spent delivering anesthesia services at Prince County Hospital, which is essential.
It was hoped that he might dedicate up to 40 per cent of his time treating non-cancer chronic pain in adults. Pediatric pain services for the Maritimes are delivered very well by the team at the IWK Children’s Hospital in Halifax. Interventional pain services for adults are shared with off-Island specialists. How does P.E.I. plan to manage its pain services in the future?
Here’s what I think. This isn’t about running out and trying to interest a bunch of physicians in managing chronic pain, although it would be great if at least some of our family physicians were keen to do so. In fairness, several family physicians have large pain practices, but they don’t appear to be able to take on additional work. Fair enough.
Many family physicians find patients with chronic pain very challenging, for a whole bunch of reasons. It is unlikely that we are going to convince them otherwise. It is also unlikely that our specialists, who see a lot of chronic pain patients, will be keen to assume their ongoing management.
We appear to have limited choices. We could:
- Throw up our hands and proclaim “Woe is us! This is the best we can do. We’re a small province. You can’t have everything. Let’s keep sending them off-Island.” Or, we could:
- Try to recruit additional physician expertise in pain management, either by recruiting a pre-trained specialist or offering to arrange and fund the training of a pain specialist from scratch. Such creatures are few and far between. If any Island physicians were interested in focusing on pain management, we could arrange additional on-the-job training, as we have done in dermatology and emergency medicine. I would be prepared to stay on in a mentorship role for the foreseeable future. Or, we could
- Take a closer look at our current physician resources and develop a plan to optimize what we’ve got and complement with non-physician resources, such as RNs with additional training, Nurse Practitioners, Physician Assistants, or chronic pain counselors [physician extenders], who tend to have a more psychosocial orientation to patient care, which is exactly what chronic pain patients need.
I believe the first option is unacceptable and, so far, we’ve been unsuccessful with the second option. We must think outside the box. If we included adult chronic non-cancer pain management in the job description for primary care nurse practitioners, especially in rural settings, I believe we could find local primary care physicians to act as collaborators. To wit, I already have had expressions of interest from several physicians in West Prince.
A part-time medical pain specialist, based in Summerside or Charlottetown, could then concentrate on managing the most complex pain cases and acting as consultant/mentor to the local physicians and physician extenders. That’s how the Nova Scotia primary pain network works. Opioid prescribing is currently a stumbling block in any non-physician-staffed pain management system.
Our regulatory bodies must allow nurse practitioners or extended role RNs to write opioid prescriptions. Maybe the regulations could be modified to allow specially trained RNs to write stable opioid prescriptions, but not new prescriptions or significant dose modifications. Maybe RNs and NPs could be allowed to monitor methadone dosing and rewrite stable prescriptions. I expect that the use of opioids in chronic non-cancer pain management will become less prevalent as we learn more about its limitations and as more effective modalities are discovered. And we should:
- Establish a working group at Health P.E.I., through the Director of Medical Affairs, to develop an operational plan for pain management services. With our aging population, this is not a problem which is going to go away. It’s up to us to do something about it.
Desmond Colohan, MD, is an Island pain physician with a keen interest in responsible social policy.