No, it isn’t COVID-19 or opioid dependency; it is the lack of effective pain management education in health professions programs.
PAEA STAR Grant-supported research published in 2019 found that 14 percent of PA programs did not include pain management in their curriculum. Commonly cited reasons included (1) insufficient time; (2) not being mandated by the ARC-PA; and (3) not being considered a priority by faculty (Yealy). For those programs with pain medicine content, it was generally spread across multiple courses. The investigators recommended the use of standardized, self-study, case-based pain management modules to help remove reported barriers of lack of faculty knowledge and adequate class time.
PA education is not alone in the need to improve pain curriculum. A recent systematic review of pain curriculum in medical schools indicated that 96 percent of medical schools in the UK and USA had no compulsory dedicated teaching in pain medicine.
Unfortunately, ARC-PA Standards (5th Ed.) have not specified “pain management” as a curriculum standard. Behavioral health and substance use disorder instruction are specifically required (B2.08d and B2.11f), and given the prevalence and co-morbidity of these disorders, this strongly suggests that chronic pain management should be viewed as ARC-PA Standards-mandated curriculum.
There are a variety of ways comprehensive pain curriculum could be implemented into a PA program and a roadmap is often helpful for such planning. The International Association for the Study of Pain (IASP) recommends that pain curriculum content includes the multi-dimensional nature of pain, pain assessment and measurement, and the management of pain and clinical conditions. Programs have the flexibility to include the content as a course or select modules to integrate with existing courses.
Recently, PAEA announced a partnership with the New England Journal of Medicine (NEJM) Knowledge+ to provide a course in the effective, evidence-based use of opioids in accordance with CDC prescribing guidelines. This no-cost CME module consists of 62 case-based questions with detailed feedback on assessing and managing acute and chronic pain, incorporating current guidelines on the appropriate use of opioids for pain management and evidence-based strategies for recognizing and treating opioid use disorders.
Table: Example of comprehensive pain content into a PA program
|ARC-PA Standard||IASP Roadmap Learning Outcome||PA Program Course|
|B1.01c||1. Recognize pain medicine as a necessary field in clinical practice for acute and persistent (chronic) pain conditions||Clinical science or specialty medicine course, or inclusion of pain medicine team as part of an interprofessional educational event|
|B1.02||2. Understand the basic science of pain-processing components such as anatomy, physiology, and pharmacology||Anatomy/physiology, medical science, and/or pharmacology courses|
|3. Identify clinical presentation of acute and persistent pain syndromes or conditions||Clinical science course|
|B2.15||4. Recognize the multidimensional aspects of the pain experience and its related management||Behavioral science or public health course|
|5. Understand pain management options appropriate for individual patients according to medical condition, medicine availability, risk-benefit balance, cost-effectiveness, culture, mental status, and evidence of efficacy*||Clinical science or pharmacology course, PAEA NEJM Knowledge+ Module|
|B1.02||6. Know the indications, contraindications, and risks* of the primary elements of multimodal pain management||Behavioral science or public health course|
|B2.10||7. Learn effective interaction with multi-professional teams involved in practicing pain medicine||Interprofessional collaborative education, which could be an event or symposium that includes the multiple pain treatment providers involved in integrated pain management|
|B2.18||8. Practice pain medicine according to ethical principles||Professionalism course|
Learning outcome number 5 requires the student to synthesize medical knowledge and use the information to make treatment decisions based on patient co-morbidities. This is where NEJM Knowledge+ Pain Management modules can be a game-changer. Although aimed at practicing clinicians, they are suitable for clinical-year PA students. The NEJM Knowledge+ course can improve their ability to recognize pain syndromes and pain medication misuse or abuse, and to provide practical instruction on how to manage both.
Pain treatment and substance abuse are both a public health crisis and a moral imperative. No patient should suffer needlessly when we can effectively treat their pain and minimize the risk for abuse. We also have an ethical obligation to recognize and treat the co-morbid substance abuse that has contributed to an epidemic of opioid related deaths.
The author wishes to acknowledge and gives thanks to her STAR Grant Pain Curriculum Project co-authors, Todd Doran and Mary Martinasek, whose knowledge and support contributed significantly to this article.
IASP website. IASP Curriculum Outline on Pain for Medicine. 2018. 24 5 2020. https://www.iasp-pain.org/Education/CurriculumDetail.aspx?ItemNumber=729.
Shipton E, Bate F, Garrick R, Steketee C, Shipton E. Systematic Review of Pain Medicine Content, Teaching, and Assessment in Medical School Curricula Internationally. Pain and Therapy 7.2 (2018): 139-161.
Yealy J, Martinasek M, Doran T. The Current State of Physician Assistant Pain Curriculum: A National Survey. Journal of the Physician Assistant Education Association 30.1 (2019): 20-26.