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Sharing the Risk: An Update to DEA & Doctors Working Together

In 2002, Shurman et al developed and launched the Share the Risk model throughout the San Diego healthcare community as an interdisciplinary means to managing chronic pain in patients. The fundamental premise of the model was that no clinician, no matter how well educated, competent, compassionate, committed, or meticulous, could adequately meet all the needs of patients with chronic and intractable pain. The model called for a multidisciplinary team approach to optimal pain management and brought together clinicians, as well as representatives from the biotech/pharmaceutical industry and the US Drug Enforcement Administration (DEA), to address the many groups affected by pain and pain management. Here, the lead authors provide a brief update to the impact of their model.


When the Share the Risk model was developed, physicians were using opioids to manage nonmalignant pain in their patients, and many were being sued for prescribing too little or too much. Several healthcare professionals were arrested and criminally charged for over-or misprescribing. The Share and Risk model served as a call to action in response to these problems. Healthcare industry actors across the San Diego area came together to address opioid phobia and to unite around the needs of chronic pain patients. A great deal of positive collaboration emerged. Yet, nearly 20 years later, we seem to be in a similar environment as the early 2000s.

The 5-Step Pain Care Plan

It is axiomatic that patients with chronic, intractable pain are among the most complex and difficult to treat in all of medicine. They invariably have multiple and often esoteric, somatic problems that may be complicated by layers of social and emotional stress or by concurrent anxiety and personality disorders. In recognition of these realities, the core of the Share the Risk model urged five “P” action items as part of any patient’s care:

  1. professional pain management delivery system using second opinions
  2. patient advocacy and educational support
  3. paperwork
  4. precautions
  5. physical therapy and integrative techniques.

The model’s authors recommended that all patients being monitored on high dose opioids also be referred to a psychologist and/or a psychiatrist if possible. In addition, it was advised that patients see an addictionologist, ideally a psychiatrist boarded in psychiatry, pain, and addiction, for a baseline opinion. There was a major focus on understanding and sharing the effect of pain on sleep, as well as on alternative treatments, such as physical therapy and water/aqua therapy. Finally, the model promoted periodic urine screens and occasional blood testing.

Between approximately 2006 and 2014, the Share the Risk group held quarterly meetings around the San Diego area, supported by various pharmaceutical groups, continuing medical education (CME) programs, and prominent med-tech companies, resulting in more effective communication and collaboration between industry and the medical community. As the group evolved, other specialists were brought in to provide second and third opinions. These included anesthesiologists, physiatrists, psychiatrists, psychologists, addictionologists, rheumatologists, sleep disorder specialists, neurologists, orthopedists, otolaryngologists, internists, nurses, and physician assistants. The group also reached out to and was able to involve many primary care physicians, as their role in treating chronic pain was growing.

Bringing in the DEA

A few years ago, our group shared how pain care practitioners were working with the DEA in southern California.Collaborative meetings brought in some of the largest turnouts in regional healthcare. These gatherings were full of passion, emotion, and energy. To date, the Share the Risk group is not aware of any other DEA field divisions with the same level of interaction with healthcare professionals. Not only have our encounters with DEA officials been positive on a local level, but also on a national level. We have worked together to create CME courses on the east and west coasts, and physicians, in turn, have learned to be more communicative and collaborative with their law enforcement counterparts, enabling them to be a true part of the Share the Risk model.

Continued Work

Today, the Share the Risk model continues to evolve. It has served as a catalyst for the development of an educational program called Emerging Solutions in Pain. This comprehensive program aims to assist pain management physicians in overcoming major practice challenges by providing practical tools and resources. The group has also turned its attention to researching and developing technologies that may aid the pain management space, including through studies of virtual reality, medical devices, overdose prevention, depression risk, and much more. One project taking place at Scripps Memorial Hospital, for example, is examining a naltrexone implant, which may last three to six months, for the treatment of opioid addiction and dependence.

Further conversation around the country is needed regarding the interaction between healthcare professionals and those in charge of monitoring opioid prescribing. This includes the DEA, state medical boards, the police, and hospital peer groups. Developed in the spirit of cooperation, the Share the Risk model has demonstrated that it is possible to develop a more constructive strategy between and among professionals dealing with the complex and growing nature of chronic pain.

The hope behind the model has always been to serve as an example for other communities throughout the country. It is the authors’ opinion that the model has great potential to expand beyond its California base to benefit the country at large.

Last updated on: March 4, 2018
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