1. The Burden of Chronic Pain
Chronic pain is a significant public health burden. This affliction affects at least
10 percent of the world’s population with an additional 10 percent developing various
forms of debilitating chronic pain every year (1). The 2010 global burden of disease
report places back pain as the leading cause of years lost to disability (2). Upon
further review of this report, it becomes apparent that eight of the top 12 conditions
responsible for global disability, which include low back pain, neck pain, arthritis,
other musculoskeletal conditions, migraines, anxiety, depression, and drug use disorder,
are conditions associated with chronic pain.
The Department of Health and Human Services (HHS), National Institutes of Health (NIH)
requested the Institute of Medicine (IOM) to address the current state of pain research,
care, and education and to explore and make recommendations for the advancement of
the science related to the field. The IOM report released in 2011 estimates that approximately
100 million suffer from chronic pain (3). Admittedly, the number of people actively
seeking care for this complex disease does not reach 100 million. However, many people
live with the burden of chronic pain, which may wax or wane during their lifetimes.
According to various estimates, 20 - 30 million individuals experience chronic pain
to such a degree that it erodes quality of life and the ability to work while forcing
them to actively seek care for this condition. Access to providers with the skills
necessary for appropriate evaluation and management of pain is limited. The majority
of sufferers seek care with their primary care providers, many of whom are primarily
in a rural setting in the state of Kansas. These providers often lack the additional
resources needed for the appropriate evaluation and management of chronic pain patients
presenting with complex behavioral manifestations and functional limitations. Without
the proper care, patients are unable to break out of the vicious cycle of increasing
pain, limited function, and generalized deconditioning.
2. CDC Guidelines for the Prescription of Opioids for Persistent Non-Cancer Pain
Juxtaposed against this scourge of pain is the epidemic of opioid abuse. Deaths related
to the abuse of prescription and non-prescription opioids reached a new crest in 2014
with 165,000 fatalities, the highest rates of overdose among people aged 25 - 54 years
(4). It will come as no surprise that the sales of prescription opioids have also
quadrupled from 1999 - 2012 (5). Whereas prior to the 2000s it was widely believed
that risk of addiction was low in chronic pain populations, recent data has revealed
that as many as 1 in 4 individuals treated with prescription opioids for long term
non-cancer pain in primary care settings may struggle with addiction (6). In light
of these concerns, the Centers for Disease Control (CDC) released guidelines for the
prescription of opioids for persistent non-cancer pain (Table 1) (7). Many of the
proposed guidelines promote the development of a treatment plan with a stepped up
approach to opioid therapy, i.e., the exploration of alternatives and attempts at
ensuring compliance and utilization of available prescription monitoring resources.
However, some controversial approaches may lead to the unintentional consequence of
reduced patient access to providers while still giving patients access to medications
that allow them to maintain some quality of life and reasonable function.
Table 1.
CDC Recommendations for Prescribing Opioids for Chronic Pain Outside Active Cancer,
Palliative, and End-of-Life Care
a
Determining When to Initiate or Continue Opioids for Chronic Pain
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for
chronic pain. Clinicians should consider opioid therapy only if expected benefits
for both pain and function are anticipated to outweigh risks to the patient. If opioids
are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic
therapy, as appropriate.
2. Before starting opioid therapy for chronic pain, clinicians should establish treatment
goals with all patients, including realistic goals for pain and function, and should
consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians
should continue opioid therapy only if there is clinically meaningful improvement
in pain and function that outweighs risks to patient safety.
3. Before starting and periodically during opioid therapy, clinicians should discuss
with patients known risks and realistic benefits of opioid therapy and patient and
clinician responsibilities for managing therapy.
Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation
4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release
opioids instead of extended-release/long-acting (ER/LA) opioids.
5. When opioids are started, clinicians should prescribe the lowest effective dosage.
Clinicians should use caution when prescribing opioids at any dosage, should carefully
reassess evidence of individual benefits and risks when increasing dosage to ≥ 50
morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥
90 MME/day or carefully justify a decision to titrate dosage to ≥ 90 MME/day.
6. Long-term opioid use often begins with treatment of acute pain. When opioids are
used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release
opioids and should prescribe no greater quantity than needed for the expected duration
of pain severe enough to require opioids. Three days or less will often be sufficient;
more than seven days will rarely be needed.
7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks
of starting opioid therapy for chronic pain or of dose escalation. Clinicians should
evaluate benefits and harms of continued therapy with patients every 3 months or more
frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians
should optimize other therapies and work with patients to taper opioids to lower dosages
or to taper and discontinue opioids.
Assessing Risk and Addressing Harms of Opioid Use
8. Before starting and periodically during continuation of opioid therapy, clinicians
should evaluate risk factors for opioid-related harms. Clinicians should incorporate
into the management plan strategies to mitigate risk, including considering offering
naloxone when factors that increase risk for opioid overdose, such as history of overdose,
history of substance use disorder, higher opioid dosages (≥ 50 MME/day), or concurrent
benzodiazepine use, are present.
9. Clinicians should review the patient’s history of controlled substance prescriptions
using state prescription drug monitoring program (PDMP) data to determine whether
the patient is receiving opioid dosages or dangerous combinations that put him or
her at high risk for overdose. Clinicians should review PDMP data when starting opioid
therapy for chronic pain and periodically during opioid therapy for chronic pain,
ranging from every prescription to every 3 months.
10. When prescribing opioids for chronic pain, clinicians should use urine drug testing
before starting opioid therapy and consider urine drug testing at least annually to
assess for prescribed medications as well as other controlled prescription drugs and
illicit drugs.
11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines
concurrently whenever possible.
12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted
treatment with buprenorphine or methadone in combination with behavioral therapies)
for patients with opioid use disorder.
aAll recommendations are category A (apply to all patients outside of active cancer
treatment, palliative care, and end-of-life care) except recommendation 10 (designated
category B, with individual decision making required); see full guideline for evidence
ratings.
3. National Pain Strategy
Recognizing the burden of chronic pain, the US congress provided a mandate to the
NIH to evaluate and make recommendations “to increase the recognition of pain as a
significant public health problem in the United States” (8). The NIH contracted with
the IOM, which developed a report calling for the development of a comprehensive population
health-level strategy to lead a cultural transformation in pain prevention, care,
education, and research (3). The National Pain Strategy is the result of HHS requesting
the Interagency Pain Research Coordinating Committee (IPRCC) to oversee the development
of such a strategy. The National Pain Strategy provides a focus on six key areas:
- Population research
- Prevention and care
- Addressing disparities in care
- Service delivery and reimbursement
- Professional education and training
- Public education and communication
Through this broad focus, the National Pain Strategy envisions a decrease in the incidence
and prevalence of acute, chronic pain across the life span from pediatric through
geriatric populations, including end-of-life care. Those suffering pain would receive
timely access to comprehensive care tailored to their biological, psychological, and
social needs based upon evidence and efficacy delivered in a patient-centric manner.
Chronic pain is a complex disease and a significant public health burden, therefore
considerable efforts need to focus on recognition of risk factors as well as mitigation,
prevention, and self-management strategies.
This bold vision will need champions at the national, regional, state, and local levels.
Disparities in care, in areas such as population research, may require large coordinated
research infrastructures. Public and professional education, on the other hand, could
be accomplished through the efforts of small groups working together toward the aims
of better care for chronic pain patients through prevention, comprehensive assessment,
and evidence-based interdisciplinary care. Outlined below are some efforts at the
local and regional level in the state of Kansas.
4. Kansas Partnership for Pain Management
The Kansas partnership for pain management is a multidisciplinary group comprised
of individuals from family medicine, anesthesiology/pain medicine, psychology, emergency
medicine, pathology, psychiatry, nursing, education, pharmacy, chiropractic groups,
bioethics, and various state and federal agencies that studied Kansas healthcare provider
and Kansas healthcare related agency concerns regarding the assessment and management
of chronic pain. This assessment revealed almost unanimous concern regarding the need
for pain management education. A comprehensive statewide, multi-year, multi-tiered
collaboration aimed at improving practice performance for the assessment and management
of chronic pain was developed. The program envisioned an inaugural statewide foundational
conference followed by 1 - 2 day primary care intensives and quality/performance improvement
(QI) projects at the practice level. The first phase of the plan was completed with
a conference in Wichita, Kansas, in November 2014. Attendance was excellent with a
diverse group of 265 healthcare providers. The conference utilized patient interviews,
discussions, role play, video vignettes, and case presentations. Ninety-five percent
of attendees strongly agreed that course objectives were met. The group is now focused
on planning the next stages of pain education in the form of intensives in two additional
areas in the state of Kansas. The intensives will include recruitment of primary care
practices in the target areas, a lecture program reviewing the foundational elements
of pain assessment and management, and the development of online modules for pain-related
quality improvement projects at the practice level (9).
5. Project ECHO Kansas
Chronic pain is a complex disease. Patients suffering from pain need access to specialty
care and education for this complex health condition. Unfortunately, there are not
enough specialists in the field of pain management to provide care for everyone who
suffers from pain, especially in rural and underserved communities. Project ECHO is
a learning and guided practice model that seeks to empower and educate providers in
remote areas through a hub-and-spoke knowledge-sharing network led by experts through
multi-point videoconferencing (10). Many different versions of project ECHO exist
around the country and focus on various chronic diseases, one of which is chronic
pain. The Kansas project ECHO for chronic pain is in the pilot stage. The goal is
to reach a select group of primary care practices scattered across the state and utilize
the ECHO model to enhance practice knowledge of the assessment and management of chronic
pain, provide teleconference access to experts in the field, and to assist them in
developing staged quality improvement projects to achieve the aims of improvement
in the management of the patient in pain.
6. Conclusion
Pain is one of the most common reasons for seeking medical care. Many Kansans will
experience pain during the course of their lives; some will go on to develop chronic
debilitating pain. The appropriate use of opioids will likely continue to be a widely
used modality along a spectrum of other treatment options ranging from self-management
techniques, other pharmacological agents, functional and psychological rehabilitation,
various surgical and minimally invasive interventions, and complementary and alternative
options to advanced pain techniques. While the national pain strategy aims to shed
more light on the public health crisis of pain as a disease, the CDC guidelines may
result in the unanticipated consequence of reduced access to primary care providers
who are willing to explore appropriate opioid therapy for the right patient at the
right time for the right reasons after other modalities have been considered and patient
and provider goals have been discussed. Thus patients find themselves caught between
a rock and a hard place. Those who had been able to maintain meaningful lives through
the responsible use of opioids, after exhaustion of other options, are being tapered
off their medications or encouraged to find another provider willing to take over
these prescriptions. It is through the education of patients, providers, and healthcare
organizations that we will be able to better navigate the turbulent waters of the
recognition of pain as a complex biopsychosocial disease requiring the appropriate
treatment. This task will include balancing the appropriate utilization of opioids,
when and if necessary, to curb and ultimately eliminate fatalities related to overdoses
of this class of medication.