LAS VEGAS — “Pain medications are neither panacea nor pariah, and experienced prescribers understand the need for a nuanced approach to pain management,” Michael R. Clark, MD, MPH, MBA, of Johns Hopkins University School of Medicine and the American Society of Pain Educators, said at the keynote session.
He identified several key elements necessary for the development of a successful individualized, patient-focused pain management practice:
- Skill in risk assessment, monitoring, and documentation
- An understanding of psychosocial factors that contribute to pain
- Familiarity with alternate and adjuvant modalities of treating pain
- Sensitivity to age- and gender-related differences in pain conditions
- The ability to motivate patients to be invested in the success of their treatment
“No one said this is easy. Given the time and resource constraints of our medical practices, it clearly is a challenge. And the complexity of the task is only compounded by a changing legal/regulatory environment in which states are starting to take matters into their own hands, crafting their own responses to the epidemic of opioid and heroin addiction,” explained Dr. Clark.
Dr. Clark then passed the baton to Charles Argoff, MD, CPE, professor of neurology and director of the Comprehensive Pain Center at Albany Medical College, who outlined his “Top 10 Reasons to Stay in the Pain Game,” or “Why The Deli Will Have to Wait.”
1. The current state of pain management. Pain is the number one reason people in the United States seek healthcare, and more than 100 million adults are affected by pain, according to a recent Institute of Medicine (IOM) report. A national pain strategy released in April 2015 proposed a new plan to improve the treatment of chronic pain both now and in the future. The strategy includes objectives and plans in key areas of pain and pain care including professional education and training, public education, communication, service delivery, reimbursement for care, preventive care, and attention to disparities in population research.
“We’ve truly only just begun in this young but growing field to really address pain management in a systemic and coordinated fashion,” Dr. Argoff said. “There are new scientific discoveries reported nearly daily and new treatments—both medical and nonmedical—that are newly available or currently in development. Now is not the time to leave the field.”
2. The public’s perception of pain. Despite the huge number of patients with chronic pain in need of care, there is still a lifetime of work to be done to educate the public and especially the media, healthcare providers, and payors that chronic pain is real and needs to be taken seriously.
“The media has had a tragic field day, focusing nearly solely on negative aspects of pain management without reporting sufficiently on the very positive and exciting progress being made in our field,” Dr. Argoff said. “Pain is often ignored or misconstrued, and steps must be taken to educate and engage the public.”
3. Not enough qualified pain management providers. Addressing the gap in the United States between the number of patients who are in pain and who are in need of evaluation and treatment, the number of pain specialists, and the number of primary care providers (PCPs) who are also involved in the care of persons in pain is a top priority. The IOM report estimates that 100 million adults in the United States experience chronic pain, yet there are only approximately 4000 pain specialists. At the same time, there are more than 400,000 PCPs, including internists, family practice providers, pediatricians, obstetricians/gynecologists, and geriatricians.
Data from a recent survey involving 3000 primary care providers, pain specialists, chiropractors, and acupuncturists indicated that 52% of patients with chronic pain are primarily treated by a PCP, 2% by a pain specialist, 40% by chiropractor, and 7% by an acupuncturist. Other survey findings indicated that certain medical therapies for pain reduction—such as long-acting opioids, anticonvulsives, and antidepressants—are prescribed much more frequently by pain specialists compared with PCPs, and that both PCPs and pain specialists reported prescribing opioids less often now due to concerns regarding regulatory oversight.
Also of interest, many survey respondents reported that they did not feel comfortable in their ability to manage musculoskeletal and neuropathic pain, but at the same time were also not likely to favor mandatory pain management education.
“Our system needs to be designed so that the need of patients with chronic pain are matched to and addressed by the appropriate practitioner,” Dr. Argoff said. “We would not expect a single provider to be able to provide every type of cardiac care to a person with a cardiovascular disorder. Why would we expect anything different from pain management providers?”
4. Optimal pain management requires a multidisciplinary effort. People in pain benefit most when their pain is assessed and addressed in an integrated fashion. This approach must be embraced by those creating undergraduate and graduate-level healthcare provider education, those paying for health care, those reporting about health care, and those receiving care. “Chronic pain does not exist in a vacuum, and the broader medical community needs to become engaged,” Dr. Argoff said.
5. Lifelong pain management education. Fewer than 50% of 170 accredited US medical or osteopathic schools currently require students to complete a pain management course as part of undergraduate medical training. Dr. Argoff asked, “How can we possibly be prepared to optimally evaluate our patients who are experiencing chronic pain, unless we receive such training?”
Pain management training needs to be mandatory and uniform at multiple levels and across all types of healthcare providers, he argued. Although progress is being made, it is not happening quickly enough.
“One consequence of this is the demonization of the person in pain. With so many healthcare providers ill prepared to appropriately and comprehensively assess and treat peoples’ chronic pain, the person in pain becomes the problem,” Dr. Argoff said.
6. Where will you be treated, if you need pain management? As non-pain management providers increasingly refuse to treat pain, and as pain specialists limit their treatment modalities due to regulatory concerns, too many patients with pain will be lost without anyone to care for them. Dr. Argoff continued, “I often ask myself what would I do if I couldn’t find someone to treat my pain?”
7. Changes to patient satisfaction measures. The Center for Medicare & Medicaid Services (CMS) is now using new measures of patient satisfaction that may significantly affect pain management. Historically there have been many approaches to measuring patient satisfaction. Now patients are asked to rate their satisfaction on a scale from 1 to 10. The number reported by CMS is the percentage of respondents who answer 9 or 10, which must be 80% or above for an institution or a provider to pass.
“Patients don’t know this when they’re given these surveys, and providers are not allowed to coach patients about this scoring system or provide them with a practice questionnaire. This scheme may have profound implications because reimbursement is tied to these scores,” Dr. Argoff said.
8. The need to teach evidence-based medicine (EBM) as it was defined. In 1996, David Sackett, the father of EBM, and his international colleagues wrote an editorial outlining what EBM is:
“It’s about integrating individual clinical expertise and the best external evidence. The conscientious, judicious, and explicit use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available evidence from systemic research. By individual clinical expertise, we mean the proficiency and judgment of individual clinicians as they acquire such through clinical experience and practice.”
Dr. Argoff argued that this is not the way EBM guidelines are currently derived, stating that many clinical guidelines do not include clinical experiences in any way, but are generated solely from literature review.
“Such reviews and therefore the guidance provided leave out most of the patients for whom we care. The patients we treat often have comorbidities that would exclude them from inclusion in many studies and disqualify them from many of the particular studies that so-called evidence-based guidelines are based on,” he said.
9. The need to address inherent conflicts of interest. Ensuring that the virtues of corporations are on a level playing field with what is best for the patient is of utmost importance. “We’ve received notice from the largest US healthcare insurers that use of Botox for chronic migraine is considered experimental, even though it’s been approved for this use since October of 2010,” said Dr. Argoff.
Under current insurance guidelines, patients with chronic migraine need to demonstrate treatment failure on as many as 3 oral treatments for 60 days each before the patient is considered an appropriate candidate for Botox, even though none of these oral treatments are approved by the US Food and Drug Administration for chronic migraine.
Many of the largest health insurers are publicly traded companies that are responsible to corporate stakeholders.“It is time for us to look at the elephant in the room and take a stand against corporations delegating how we should treat our patients,” Dr. Argoff said.
10. Remember why you became a healthcare provider. “I hope you all continue to be great healthcare providers,” Dr. Argoff concluded. “We are all here to listen to and learn from our colleagues, and to speak and interact with each other, all in the name of improving the care of the people with chronic pain who depend on us.”