Relieving Pain in America A Blueprint for Transforming Prevention, Care, Education, and Research (2011) / Chapter Skim
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3 Care of People with Pain
3 Care of People with Pain
Pages 113-178
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From page 113... ...
And most people with severe, persistent pain still do not receive -- and often are not offered -- systematic relief or the comprehensive, integrated, evidence-based assessment and treatment that pain care clinicians strive to provide. Currently available treatments have limited effectiveness for most people with severe chronic pain.
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From page 114... ...
The resources available to help the tens of millions of Americans with acute and chronic pain are few and stretched thin. Nor is the path to maximum achievable relief straightforward or clear of pitfalls.
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From page 115... ...
In many different cases, especially for people with complex, chronic pain conditions, biopsychosocial care (taking into account patients' unique bio logic and genetic constitution, their psychological and emotional composition and reaction, and the societal and environmental framework within which they reside and function) has been shown to be advantageous.
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From page 116... ...
Instead, a biopsychosocial framework takes into account the rich range of potential causes, effects, and treatment strategies. Pain care is available in many settings, and a patient's journey may include any or all of the following steps, in sequence or in any order and with any number of repeat visits with the same or new clinicians and advisors: • self-management, perhaps in consultation with family and friends -- whose prior experience and knowledge, whether accurate or not, will play a key role -- but with little systematic guidance or intervention from a clinician; • primary care, where practitioners may employ a variety of management strategies, including use of prescription drugs and suggestions for exer cise, physical therapy, or weight loss, perhaps after some consultation with specialists; • specialist care, from a professional in diagnosing and treating an under lying disease (cancer, heart disease)
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From page 117... ...
Self-Management Self-management is almost always the first step in a person's journey to relieving pain, and is one that is returned to repeatedly. Because severe pain strongly influences virtually all aspects of a person's quality of life, and because treatment often is insufficient and involves several specialties and professions, the burden of controlling pain falls most heavily on people in pain and their families.
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From page 118... ...
. And a program of manual therapy, exercise, and education for chronic low back pain showed a significant treatment effect, maintained at 1-year follow-up (Moseley, 2002)
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From page 119... ...
. It is no wonder, then, that primary care practitioners are an early step in the pain care journey, treating 52 percent of chronic pain patients in the United States based on a national mail survey of primary care physicians, physician pain specialists, chiropractors, and acupuncturists (Breuer et al., 2010)
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From page 120... ...
, with about 4,000 to 6,000 members each, are the American Academy of Pain Management (consisting of anesthesiologists, chiropractors, physical therapists, psychologists, and others) , the American Society of Regional Anesthesia and Pain Medicine (anesthesiologists)
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From page 121... ...
The interdisciplinary model incorporates assessment and diagnosis, not just therapy. It is an integrated, coordinated, and multimodal approach to care targeting multiple dimensions of the chronic pain experience -- including disease management, reduction in pain severity, improved functioning, and emotional well-being and health-related quality of life -- that is developed through a comprehensive evaluation by multiple specialists (usually physicians, nurses, psychologists or other mental health professionals, rehabilitation special ists, and/or complementary and alternative medicine [CAM]
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From page 122... ...
. Interdisciplinary approaches for chronic pain have been supported by numerous studies from many different countries and study populations, including • systematic reviews of treatment and rehabilitation for low back pain (Guzmán et al., 2001; van Middelkoop et al., 2011)
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From page 123... ...
Only three of these thus far are veterans' facilities, despite the Depart ment of Veterans Affairs' important role in pain care. The American Academy of Pain Management accredits some 46 individuals and centers (American Academy of Pain Management, 2011)
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From page 124... ...
. Initial acute pain management may include • pharmacologic therapy, for example, with analgesic drugs; • advice, reassurance, or distraction delivered by a health professional; • formal psychological interventions, including stress and tension reduc tion and cognitive-behavioral interventions;
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From page 125... ...
; • nancial means, health insurance coverage, and other factors affecting access fi to care; • ikely adherence to prescribed treatments, including medications, physical l therapy, and diet; • ealth beliefs -- for example, that drugs or doctors can solve even the most h difficult health problems or, conversely, that medications often prescribed for persistent pain are too dangerous; • ultural, spiritual, and religious beliefs; and c • evel of health literacy or English proficiency and cognitive, speech, hearing, l or visual impairments that can affect communication with care providers. Environmental Factors • iving and work situations and associated risks of injury and physical and l emotional strain; • he context of pain, that is, where the person is and what he or she is doing t when pain occurs; • amily history and modeling of disease and wellness behavior and its reinforce f ment or suppression of pain behavior; • oping resources, including support from significant others and adequate c financial support; • ultural background and involvement, community response, and support from c other people; • nformation obtained from the Internet, other media, and other people; and i • ast experiences with health care providers.
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From page 126... ...
. In general, an integrative approach to persistent and severe pain is beneficial, but even an integrative approach may fail large numbers of patients.
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From page 127... ...
In addition, EDs are a common site of pain care. A busy hospital ED would appear to be one of the least promising care sites for chronic pain patients, given
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From page 128... ...
. Between 10 and 50 percent of people having common surgical operations -- groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery -- go on to experience chronic pain, often due to damage to nerves in the surgical area during the procedure (Kehlet et al., 2006)
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From page 129... ...
. The rising rate of reported chronic pain (see Chapter 2)
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From page 130... ...
Madans, Associate Director, Science, National Center for Health Statistics, Centers for Disease Control and Prevention, February 8, 2011. 5 The National Ambulatory Medical Care Survey is a national survey of nonfederal office-based physicians engaged primarily in direct patient care.
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From page 131... ...
. A systematic review of 18 randomized controlled trials found no strong evidence for or against using injection therapy to treat subacute or chronic low back pain (Staal et al., 2008)
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From page 132... ...
Medicare data show that between 2000-2001 and 2005-2006, the number of hip replacements grew by 15 percent, the number of knee replacements by 48 percent, and the number of shoulder replacements by 67 percent. A portion of these surgeries results from Americans' increased longevity; people outlive their joints and need to have them replaced.
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From page 133... ...
. On the other hand, a meta-analysis of 30 randomized controlled trials involving chronic low back pain showed that while behavioral therapy was more effective than usual care in the short term, it was no more effective than group exercise in the intermediate to long term (Henschke et al., 2010)
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From page 134... ...
In a systematic review of 43 studies of exercise for chronic low back pain, the researchers concluded that only 6 showed statistically significant and clinically important results in im proving functioning, and only 4 showed such results in reducing pain intensity (van Tulder et al., 2007)
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From page 135... ...
Acupuncture appears to affect several mechanisms in the brain and spinal cord, including those involved in pain and inflammation. A systematic review supports its use in postoperative pain management (Sun et al., 2008)
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From page 136... ...
Of interest, a systematic review of 23 clinical trials found moderate evidence that acupuncture and sham acupuncture are, in roughly equal measure, more effective than no treatment for chronic low back pain (Yuan et al., 2008)
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From page 137... ...
-- A woman with fibromyalgia, vulvodynia, and interstitial cystitis 8 Issues in pain care discussed in this section of the chapter are difficulties in measuring pain, the adequacy of pain control in hospitals and nursing homes, pain and suffering at the end of life, access to opioids and concerns about their use, insurance incentives, and the reporting of pain. Difficulties in Measuring Pain As discussed in Chapter 1, the experience of pain is influenced by a range of physical, psychosocial, and behavioral factors.
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From page 138... ...
Health professionals' general awareness of the importance of pain and recognition of the need to ask patients about it have been buttressed by efforts of the Joint Commission to establish and enforce pain management standards (Phillips, 2000)
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From page 139... ...
. In a veterans' outpatient clinic, monitoring pain as a fifth vital sign failed to improve pain management as the assessment was not followed up with recommended treatment, even for patients reporting substantial pain (Mularski et al., 2006)
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From page 140... ...
Thus there exists a clear need for more objective measures for pain. Adequacy of Pain Control in Hospitals and Nursing Homes Hospitalized patients experience both acute and chronic pain; patients often experience acute pain following a surgical procedure, or they suffered from chronic pain prior to admission.
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From page 141... ...
. Opioids and other pain management strategies are important in addressing pain associated with terminal illness, but clinicians should be aware of the risk of
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From page 142... ...
It was a terrible time in my life. -- A person with chronic pain9 Although opioid analgesics often are indicated for chronic severe pain, people with such pain and institutions such as nursing homes can have difficulty obtaining them for various reasons.
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From page 143... ...
patients' difficulty in obtaining opioids to pressures on physicians from law enforcement and risk-averse state medical boards. Federal and state drug abuse prevention laws, regulations, and enforce ment practices have been considered impediments to effective pain management since 1994, when the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]
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From page 144... ...
. In the wake of criticism of state medical boards' actions against physi cians who prescribed large amounts of opioids, the Federation of State Medical Boards developed a model policy in 1998 -- since adopted by many individual state boards -- that supports use of opioids for pain management if appropriately documented by the treating physician (Federation of State Medical Boards of the United States, 2004)
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From page 145... ...
sponsored a national online survey of 400 board-certified U.S. primary care physicians who "fairly commonly" prescribe opioids and found con continued misperceptions about misuse and abuse of opioids (American Pain Foun dation, 2010a)
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From page 146... ...
Opioid medications present some risk of abuse by patients as well. A struc tured review of 67 studies found that 3 percent of chronic noncancer pain patients regularly taking opioids developed opioid abuse or addiction, while 12 percent developed aberrant drug-related behavior (Fishbain et al., 2008)
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From page 147... ...
. Thus far at least, few primary care physicians prescribing opioids for chronic noncancer pain appear to be using urine testing or other strategies to reduce the risk of opioid abuse (Starrels et al., 2011)
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From page 148... ...
. On the whole, payers do not encourage interdisciplinary team care, which, as discussed earlier, often is an effective pain management strategy.
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From page 149... ...
Under current reimbursement approaches, it may be unreasonable to expect primary care practitioners to devote extensive resources to managing pain in patients simultaneously experiencing multiple health problems, such as diabetes, a history of family violence, and fibromyalgia. One way (among many)
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From page 150... ...
Some unique attributes of pain in the elderly that might be addressed by such quality measures include • difficulty using certain pain intensity scales; • increased vulnerability to neuropathic pain (but decreased vulnerability to acute pain involving visceral pathology) ; • prolonged recovery from tissue and nerve injury; and • differences, compared with younger adults, in relationships among psychosocial factors (Gagliese, 2009)
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From page 151... ...
Nursing home residents report their pain to nurses and nursing assis tants, physical and occupational therapists, medical directors, and patient activity coordinators. As noted earlier, the formal health care system is not alone in receiving complaints of acute or persistent pain or noticing pain in others (Thernstrom, 2010)
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From page 152... ...
Wider access to authoritative information about pain would help not only physicians and other health professionals but also many other categories of people respond appropriately to a person's pain. As noted in Chapter 2, although many people report pain in various ways, many others do not complain at all even when it would be appropriate for them to do so (Keefe et al., 2005)
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From page 153... ...
Magnitude of the Problem Approximately 100 million American adults experience pain from common chronic conditions, and additional millions experience short-term acute pain (Chapter 2)
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From page 154... ...
A third important barrier to pain care is the need for expanded formal train ing in medical, nursing, and other health professions educational programs, as well as enhanced continuing education. Most people in pain are cared for by primary care physicians who likely received little initial training or experience in best practices in pain management.
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From page 155... ...
If health care providers do not know how to solicit information about a person's experience with pain or how to treat pain when described, that is a failure of training; if they do know how to do so and yet do not, that is a failing of a different kind. Fourth, evidence-based protocols and guidelines exist to assist primary care practitioners in treating people with chronic pain.
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From page 156... ...
System and organizational barriers, such as the lack of capacity for frequent visits when necessary and the lack of time to conduct com prehensive assessments and patient education, obstruct individualized care. Much more could be done to educate clinicians, patients, and the public about pain and pain management, but education alone will be ineffective in the absence of systems that permit -- or encourage -- them to act on that knowledge.
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From page 157... ...
Geographic Barriers As noted in Chapter 2, America's rural areas have shortages of primary care physicians and certainly have few pain care specialists. As a result, military veterans, farm workers, people who are chronically ill, and others living in rural areas are deprived of competent pain management or, like some wounded warriors from the Iraq and Afghanistan wars, must move with their families to an area where they can find suitable care (President's Commission on Care for America's Returning Wounded Warriors, 2007)
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From page 158... ...
. Relatively early, in 1998, the department developed a brief but comprehen sive National Pain Management Strategy that called for national coordination and national standards, including use of the fifth vital sign approach described earlier (VHA, 1998)
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From page 159... ...
Care at interdisciplinary pain centers includes advanced diagnostic and medical management, rehabilitation services for com plex cases involving comorbidities (such as mental health disorders and traumatic brain injuries) , and integrated services for patients with both chronic pain and substance use disorders.
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From page 160... ...
. lead to a comprehensive pain management strategy that is holistic, inter disciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for Soldiers and other patients with acute and chronic pain.
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From page 161... ...
Pain care must be tailored to each person's experience. Pain management takes place through self-management, primary care, specialty care, and pain centers.
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From page 162... ...
Health care provider organizations should take the lead in developing educational approaches and materials for people with pain and their families that promote and enable self-management. These materials should include information about the nature of pain; ways to use self help strategies to prevent, cope with, and reduce pain; and the benefits, risks, and costs of various pain management options.
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From page 163... ...
Provide educational opportunities in pain assessment and treatment in primary care. Health professions educa tion and training programs, professional associations, and other groups that sponsor continuing education for health professionals should develop and provide educational opportunities for primary care practitioners and other providers to improve their knowledge and skills in pain assessment and treatment, including safe and effective opioid prescribing.
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From page 164... ...
Medicare, Medicaid, workers' compensation programs, and private insurers should • C reate incentives to support and adequately reimburse primary care providers' delivery of integrated, interdisciplinary pain assessment and treatment, as well as advanced specialty care for people with complex pain. The committee encourages demonstration projects of the Centers for Medicare and Medicaid Services to foster models of this kind of patient-centered pain management.
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From page 165... ...
2008. Pain management in sickle cell disease: Palliative care begins at birth?
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From page 166... ...
2010. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: A national survey.
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From page 167... ...
2008. Veterans Affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates.
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From page 168... ...
2010. Review of regulatory pro grams and new opioid technologies in chronic pain management: Balancing the risk of medica tion abuse with medical need.
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From page 169... ...
2006. Long-term opioid contract use for chronic pain management in primary care practice: A five-year experience.
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From page 170... ...
2006. Assessing the appropriateness of pain management prescribing practices in nursing homes.
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From page 171... ...
2009a. Pharmacotherapy of chronic pain: A synthesis of recommendations from systematic reviews.
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From page 172... ...
2004. Randomized clinical trial of the effectiveness of a self-care intervention to improve cancer pain management.
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From page 173... ...
2006. Measuring pain as the 5th vital sign does not improve quality of pain management.
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From page 174... ...
2007. The problem of pain management in nursing homes.
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From page 175... ...
2010. Impact of a brief intervention on patient communication and barriers to pain management: Results from a randomized controlled trial.
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From page 176... ...
2007. A primer on health-related quality of life in chronic pain medicine.
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From page 177... ...
2008. Acute pain treatment.
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