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Looking at root causes of opioid addiction in the U.S.: ‘We as physicians aren’t properly educated’

Kelly Moffitt | St. Louis Public Radio
Dr. Michael Bottros, the director of acute pain service at Barnes-Jewish Hospital, shared his take on the root causes of opioid addiction in the U.S.

In U.S. medical schools, a total of nine hours is required in pain management training for doctors. That’s 0.3% of total time in medical school and, to compare, veterinarian schools spend more than 500x more time spent learning to treat pain in animals.

That’s according to a study conducted by Johns Hopkins in 2011 and cited by Dr. Michael Bottros, the director of acute pain service at Barnes-Jewish Hospital.

“We as physicians aren’t properly educated,” said Bottros, referencing that improper pain management tactics and prescriptions as a root source of opioid addiction, which has reached epidemic-levels in the United States.

“If I think I can trust a doctor who has had 9 hours of education on this, I am a fool,” said Dave, a caller to Monday’s St. Louis on the Air, when Bottros joined host Don Marsh to talk about efforts to better educate pain management physicians and their patients about responsible opioid use and some alternative methods of pain management.

From 1999-2014, there were over 165,000 deaths related to opioid overuse and overdose. Over forty people per day are dying from it, Bottros said. The CDC claims an even higher number: 78 people per day die from an opioid overdose. 

How did we come to this place?

Bottros said that the way doctors treat pain has been formed by over 100 years of policy. In 1911, one in 400 Americans was addicted to opium. By 1914, the Harrison Narcotics Act was passed, which regulated the importation and distribution of opium in the U.S.

At the time, addiction wasn’t viewed as an illness and doctors were punished for continuing the treatment of legitimate pain using opioids after the Harrison Act was passed.

What followed was decades of reaction to the restrictions and many articles being published on the presumed safety of opioids. By 1997, a variety of “intractable pain statutes” was adopted by federal state medical boards that said “we had the right and moral obligation to treat pain,” Bottros said. “Through a variety of channels and pharmaceutical companies, the treatment of chronic, cancer-related and end-of-life pain was stretched out into chronic non-cancer pain. Pain treatment became synonymous with opioid use.”

“Unfortunately, that led to our uni-dimensional, uni-modal approach to pain management,” Bottros said.

While doctors have been over-prescribing opioid painkillers, patients have also become used to the medications and that has led to dependency. Big pharmaceutical companies, like Purdue Pharma, aren’t helping either as they wage aggressive marketing campaigns for drugs like OxyContin, Bottros said.

New CDC guidelines suggest that doctors should not use opioids as first-line therapy.

“I unfortunately spend quite a bit of time setting expectations for patients,” Bottros said. “Multi-disciplinary approaches to pain management are really the best and most proven technique to coping with people’s pain. It might not take away the pain 100 percent, but it is trying to get you to the most functional state. Physical therapy, injections, exercise, different medications can be helpful.”

The results of a 2014 National Survey on Drug Use and Health found that people who use opioids illicitly, for non-medical reasons, first received opioids from a friend or relative. That’s made finding new or readdressing old methods of treating pain outside of opioid medication even more important to Bottros.

One of the alternatives to pain treatment that Bottros advocates for is called radiofrequency ablation, which is covered by insurance, he said.

“It has been around for a long time,” Bottros said. “What it entails is targeting small nerves, not major nerves, that can relay sensory information from these arthritic joins—low back pain, knee pain. If we numb up those nerves and your pain is improved as a diagnostic measure, then we have a better sense that is a cause of our pain. We can zap those nerves with radiofrequency ablation and that can provide relief for 6 months to a year. Nerves will grow back, but we can repeat the procedure. It has become a mainstay for my patients.”

St. Louis on the Air brings you the stories of St. Louis and the people who live, work and create in our region. St. Louis on the Air host Don Marsh and producers Mary Edwards, Alex Heuer and Kelly Moffitt give you the information you need to make informed decisions and stay in touch with our diverse and vibrant St. Louis region. 

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Kelly Moffitt joined St. Louis Public Radio in 2015 as an online producer for St. Louis Public Radio's talk shows St. Louis on the Air.

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