Share the Risk Model
Physicians prescribing opioids for pain relief and, in particular. non-malignant pain, are being sued for giving too little, giving too much, or even murder.1,2 Several publications have made the statement that “17% of doctors who treat pain are investigated each year and a pain treating physician is arrested and charged criminally somewhere in the U.S. daily.”3,4
The Share the Risk Model (STR) has evolved in response to these problems. The basic theme is a call for action. The model addresses the opioid phobia that continues to manifest itself among physicians, patients, the media, and various government entities. The goal has been to unite physicians and other health care professionals who treat chronic pain in the San Diego area. It is axiomatic that patients with chronic and intractable pain are among the most complex and difficult to treat in all of medicine. They invariably have multiple and often esoteric somatic problems, predictably complicated by layers of social and emotional stress, or by concurrent anxiety and personality disorders. In recognition of these realities, the Share the Risk Model’s fundamental premise is that no physician—no matter how well educated, confident, compassionate, committed, or meticulous—can adequately meet all the needs of the patients with chronic and intractable pain. Instead, the model calls for a multi-disciplinary team approach to treat the chronic pain patient.
Dr. Joseph Shurman first developed the model’s basic principles in January 2002 in San Diego. Inter-disciplinary teams have been shown to improve patient care in a number of complex clinical situations and also deliver the best possible care to this challenging population. A variety of perspectives can be a source of strength and creativity, as well as contribute to goal-oriented coalitions across disciplines.
Chronic pain is a significant problem in the U.S. today. Approximately 35% of the population suffers from chronic pain. Over 50 million Americans are partially or totally disabled by chronic pain. Over the age of 50, one out of two people experience chronic pain. Under-treatment of chronic pain runs as high as 50%.5 Treatment is often inadequate and associated with a high economic and psychological cost. This population will be increasing rapidly over the next several decades. The effects of under-treatment of pain can be devastating, leading to depression (suicide), anxiety, loss of sleep, social and sexual dysfunction, loss of work, weakness, fatigue, gastrointestinal distress, hypertension, and tachycardia.”6 The JCAH has made pain management a major criteria for the accreditation of hospitals and pain is now recognized as the fifth vital sign.7
In the late 1980’s and early 1990’s, a major breakthrough occurred when opioids began to gain acceptance as a legitimate therapy for chronic non-malignant pain. Opioids are the most effective analgesics known to mankind and have been used for thousands of years. When opioids are titrated properly, patients can achieve excellent pain relief. This may lead to a dramatic improvement in the quality of life and often enables patients to return to a productive lifestyle. Opioid therapy for non-malignant pain is gaining national acceptance but is still controversial.
On May 19, 1998, the Federation of State Medical Boards published the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain (revised in 2004).8 These Guidelines recognize that “controlled substances,” including opioid analgesics, may be essential in the treatment of acute pain due to trauma or surgery and in chronic pain — whether due to cancer or non-cancer origins.
In their October 23, 2001 Consensus Statement, the DEA and 21 healthcare organizations agreed that “effective pain management is an integral and important aspect of the quality of medical care and pain should be treated aggressively.” They also noted that opioids are often “the most effective way to treat pain and the only treatment option to provide significant relief.” They further stated “that focusing only on the abuse potential of the drugs, however, could erroneously lead to the conclusion that these medications should be avoided when medically indicated, generating a sense of fear rather than respect for their legitimate properties.”9
Despite these encouraging developments, physicians prescribing opioids for chronic non-malignant pain have been under increasing pressure over the past several years. On the one side, they are under pressure from patients who demand and expect adequate pain relief. On the other side, are families, insurance carriers, or other third parties who may argue that the patient is over-medicated. When the situation becomes adversarial, the doctor may be sued for over-prescribing. In some cases, where deaths have occurred, physicians have even been prosecuted for murder. And despite its stated support for adequate pain relief, the DEA continues to investigate and prosecute doctors—in particular, those who prescribe high doses of opioids. All these realities have had a “chilling effect” on the practice of pain medicine and often place the prescribing physician in a no-win situation.
Share the Risk Model
The Share the Risk Model has evolved in response to these problems. The core of the STR model is elaborated through the five P’s, as follows:
P1 — Professional Pain Management Delivery System
P2 — Patient Advocacy & Educational Support
P3 — Paperwork
P4 — Precautions
P5 — Physcial Therapy & Integrated Techniques
P1 — Professional Pain Management Delivery System
This category includes pain specialists, psychologists/psychiatrists, pain addiction specialists, pharmacists, and other agents and organizations. The following sections describe these contributors.
Pain Specialist. The core of the STR model is a second or third pain management opinion. The authors prefer, if possible, to use a specialist who is not associated with the referring physician. For example, the senior author, Dr. Joseph Shurman, is an anesthesiologist who uses second and third opinions from a neurologist and a physical medicine specialist. These specialists review the patient’s medication plan and may offer other perspectives and alternative treatments. The authors have tried to unite competing pain specialists within the region and assure them that when a second opinion is rendered; the patient will not be transferred without the approval of the referring physician.10 In today’s litigious climate, having a second opinion — even within your medical group — is better than going it alone. In more remote areas, the authors recommend networking with the closest regional group, preferably within an hour’s car ride.
Psychologist/Psychiatrist. The senior author recommends that all patients on high dose opioids see a psychologist and/or a psychiatrist who, if possible, has some pain management expertise. In the majority of cases, the patients concur and see a therapist (the senior author makes it mandatory). Some patients are initially resistant but, over time, are grateful for the referral.