Faculty Perspectives in Chronic Pain, Part 2 of 5
Finding Solutions to Public Health Issues in Chronic Pain
The main article in this publication discusses the need for global education and advocacy efforts to improve the care of patients with chronic pain. The Institute of Medicine report on relieving pain stresses the importance of expanding education efforts to multiple stakeholders, including patients, the general public, and healthcare providers, on such broad topics as the causes and consequences of pain, available treatment options, and consideration of chronic pain as a biopsychosocial disorder.1 Currently, the biopsychosocial model of pain and disability is the most heuristic approach to understanding and treating conditions of chronic pain, and highlights the challenges of treating these patients.2 This model describes how pain and disability can interact with biological, psychological, and social factors, which may perpetuate and worsen a patient’s clinical condition and result in chronic pain syndromes that are complex and refractory to treatment over time.3 It also explains how pain is a unique and individualized experience related to psychosocial factors (eg, emotion and cognition) that modulate clinical presentation and disability. In turn, pain and disability may trigger additional psychosocial responses and emotional distress (eg, anxiety, depression, fear), which become important comorbid conditions to address in the treatment of chronic pain.4
Treating patients effectively within this biopsychosocial framework requires an understanding of the distinction between interdisciplinary and multidisciplinary approaches to treatment. Specifically, a multidisciplinary assessment involves several healthcare providers (eg, physician, psychologist, physical therapist, occupational therapist) who may or may not be located in the same facility.3 Because of this, the integration of their services, as well as communication among providers, may be limited. Even in instances where various treatment providers are located within the same premises, the use of alternate treatments with separate goals may still be considered as providing multidisciplinary care, especially if the contributions of their peers have not been taken into account.
On the other hand, interdisciplinary care consists of greater coordination of services in a comprehensive program and more frequent communication among healthcare professionals (eg, pain specialists, mental health providers, physical or occupational therapists, nurses) all providing care at the same premises. Primary care providers in particular are an integral part of the interdisciplinary team, as they play a key role in promoting treatment adherence and monitoring long-term outcomes.3
The author of the main article further highlights particular gaps in knowledge that exist among healthcare providers, including the appropriate use of prescription opioids for chronic noncancer pain. Several issues contribute to this gap, starting with a lack of data on the long-term effectiveness and safety of opioids administered in these circumstances. Systematic reviews that examined randomized controlled trials of opioid use for chronic noncancer pain have shown at least moderate improvements in pain, function, and disability for these drugs compared with placebo; however, these findings were limited by short-term follow-up over several weeks and high patient dropout rates due to a lack of efficacy of the study drug and/or the presence of treatment-related side effects.5-11 Clearly, more research is needed to guide the appropriate use of prescription opioids in treating chronic pain. In addition, most existing clinical guidelines for mitigating risks when prescribing opioids are only supported by lower quality data (eg, observational studies) and expert opinion.12 However, guidelines generally do support a trial period when initiating opioid therapy; individualized therapy based on risk assessment; ongoing interdisciplinary assessment; gradual dose escalations; and regular follow-up visits. These guidelines will likely be revised as newer findings become available.12 Thus, gaps in provider knowledge represent the end product of this controversial topic, and provider education will need to be continually reassessed as new research findings and corresponding clinical recommendations emerge.
The main article also highlights the importance of patient education. For patients to effectively combat their pain, active coping skills are required, rather than remaining passive, dependent, and hopeless. Psychological therapies for chronic pain focus on patient coping, adaptation, self-management, and a reduction of disability.13 One of the major theoretical approaches to psychological treatment uses cognitive behavioral therapy to replace maladaptive behaviors and cognitions, with more adaptive responses to chronic pain.4 Taken as a whole, psychological treatment results in decreased pain, less disability, improved quality of life, and better mood.4,14 Given the myriad benefits of psychosocial education in treating chronic pain, resources need to be allocated to both patient self-management and psychological education.
Beyond provider and patient education, the timely, tailored education of family, caregivers, and the public at large may potentially decrease the lag time between symptom onset and adequate treatment. Such education may empower patients and their families to become their own advocates within the healthcare system. In addition, patients with chronic pain are more likely to understand and embrace the biopsychosocial model of pain and, therefore, adapt active pain-coping skills. Public education regarding pain is important, to help promote strategies for its prevention and self-management, as well as to identify appropriate treatment-seeking behaviors. In addition, education regarding appropriate prescription opioid use, storage, and disposal could enhance the overall safety of these medications, thereby limiting potential devastating outcomes, such as death from medication overdose.
Moving forward, an educated public is likely to play a key role in advocating for patients with chronic pain, including the crucial aspect of proper reimbursement for essential services provided for interdisciplinary pain management. Additionally, reimbursement policies must be reviewed and amended as necessary, to reduce the number of disparities that exist within the pain treatment arena. One particular area in need of continued advocacy is reimbursement for psychosocial services, which have proven to be efficacious and safe. Clearly, widespread efforts to improve the education of healthcare providers, patients, families, caregivers, and the general public are an essential component to improving the treatment of patients with chronic pain. Improved education among all of these stakeholders is likely to foster advocacy for the resources necessary to properly treat all patients suffering with pain.
- Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. Washington, DC: The National Academies Press; 2011. http://books.nap.edu/openbook.php?record_id=13172&page=17. Accessed December 23, 2014.
- Gatchel RJ, Peng YB, Peters ML, et al. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133: 581-624.
- Gatchel RJ, McGeary DD, McGeary CA, et al. Interdisciplinary chronic pain management: past, present, and future. Am Psychol. 2014;69:119-130.
- Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7:779-793.
- Furlan A, Chaparro LE, Irvin E, et al. A comparison between enriched and nonenriched enrollment randomized withdrawal trials of opioids for chronic noncancer pain. Pain Res Manag. 2011;16:337-351.
- Papaleontiou M, Henderson CR Jr, Turner BJ, et al. Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2010;58:1353-1369.
- Furlan AD, Sandoval JA, Mailis-Gagnon A, et al. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174:1589-1594.
- Mayyas F, Fayers P, Kaasa S, et al. A systematic review of oxymorphone in the management of chronic pain. J Pain Symptom Manag. 2010;39:296-308.
- Kuijpers T, van Middelkoop M, Rubinstein SM, et al. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J. 2011;20:40-50.
- Kalso E, Edwards JE, Moore RA, et al. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain. 2004;112:372-380.
- White AP, Arnold PM, Norvell DC, et al. Pharmacologic management of chronic low back pain: synthesis of the evidence. Spine (Phila Pa 1976). 2011;36:S131-S143.
- Nuckols TK, Anderson L, Popescu I, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014;160:38-47.
- Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet. 2011;377:2226-2235.
- Eccleston C, Morley SJ, Williams AC. Psychological approaches to chronic pain management: evidence and challenges. Br J Anaesth. 2013;111:59-63.
Chronic pain is an issue of major importance for US payers. Although the management of chronic pain is complex and requires multiple medical interventions and therapies, one of the mainstays of treatment is the appropriate use of opioid therapy.1 In this regard, payers are tasked to maintain a balance that [ Read More ]
In the main article in this publication, the author points out various shortcomings of chronic pain management in the United States. In this commentary, I would like to address some of the reasons for such shortcomings as they pertain to the use of opioids for the management of chronic noncancer [ Read More ]