The “Decade of Pain Control and Research”: Part II

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Part II: What Are The Greatest Challenges Ahead?


In the year 2000, the Joint Commission on Accreditation of Healthcare Organizations released new standards for the assessment and management of pain in the facilities they accredit and certify. C. Richard Chapman, Ph.D., then the President of the American Pain Society, described this as “a giant step…a major leap forward”. A few months later Congress passed and the President signed a law that declared the ten-years beginning January 1, 2001 as the Decade of Pain Control and Research.

Kathryn L. Hahn, Pharm.D.:

Kathryn L. Hahn, Pharm.D. is Affiliate Faculty, Oregon State University College of Pharmacy, Chair, Oregon Pain Management Commission, American Pain Foundation State Action Leader, and Pharmacy Manager, Bi-Mart Corp. She also serves on the Board of Directors of the Academy of Pain Management.

"What is your personal evaluation of the greatest challenges ahead, as we enter the next decade?"

I think the challenge for the next decade is to apply what we have already learned. We are not always good at employing the tools we have created. For example, we have learned how patients can misuse medications, and that we can now make new drug formulations that are not as easy to abuse. As these have come into use, in my experience this means that patients who were using their pain medication not as prescribed or for “chemical coping”, will learn that their medications will not have that same immediate effect. Since these new formulations have been available I have learned that there are many more “abusers and misusers” than I had thought, and that we will have to hold their hands through this difficult transition for them. While insurance companies may be reluctant to pay for the new abuse deterrent or tamper-resistant formulations, it is ethically the right thing to do.

Another challenge facing us immediately is conducting mass education of the public and providers to increase the safety of prescription pain medications once they are dispensed. The National Center on Addiction and Substance Abuse reports that 70% of children who abuse prescription drugs get them from family or friends. Providers must educate and the public must understand that keeping prescription meds safe in the home, never sharing them, and discarding them when no longer needed in an appropriate way, is vital to public health.

I am very concerned however, that in the name of safety, patients may have their access to the medications they need limited. I believe this may lead them to go without (including all the ramifications of under-treatment) or to go “underground” as they do in most places when they are seeking marijuana. I don’t think it makes sense, that with all we have learned in the past decade, to now limit access to appropriate pain management including prescription pain medications.

The changing demographics in the US also will have an impact. We have an aging population who are increasingly likely to have a pain condition. But this generation is made up of the “baby boomers”, and they will demand effective treatment for the management of their pain. They will be “activist” patients who will be more proactive and loud.

I think that in the future, it will be the patient who holds the cards. Pain patient advocates are currently feeling that they are on the defensive as they try to stop efforts to limit appropriate access to pain medications, but in the end, the voice of the public will prevail. I think of the AARP as the model for this, and that we should learn from their experience.

Click here to read Part I of this two-part Clinical Roundtable.

Part II: What Are The Greatest Challenges Ahead? 

In the year 2000, the Joint Commission on Accreditation of Healthcare Organizations released new standards for the assessment and management of pain in the facilities they accredit and certify. C. Richard Chapman, Ph.D., then the President of the American Pain Society, described this as “a giant step…a major leap forward”. A few months later Congress passed and the President signed a law that declared the ten-years beginning January 1, 2001 as the Decade of Pain Control and Research.

Carol Curtiss, RN, MSN:

Carol Curtiss, RN, MSN, is a consultant for education and program development for pain and symptom management. She also teaches at the Tufts University School of Medicine Programs in Pain Research, Education and Policy (PREP) in Boston, MA.

"What is your personal evaluation of the greatest challenges in the decade ahead?"

Some of the greatest challenges that lie ahead are related to educational deficits and to patient access. There continues to be very little education about pain in medical schools, schools of nursing and pharmacy schools. Even though pain is a persistent common report by our patients, education and implementing research about pain often go onto the back burner. A pharmacy student recently told me, “We spend an hour on opioids and then we move on to the more glamorous medications”.

Additional challenges include the stigma directed to people with persistent pain in the community and the lack of health care providers who treat pain. We have an increasingly aging population who are more likely to need the care of a trained pain expert, but we are facing a likely shortage of primary care physicians and nurses as well as pain experts. It is hard to imagine the typical primary care provider taking on more than they already do. Unfortunately, our health care system has not been set up to deal with chronic illness and increasingly, that is what is needed. I believe this time is the most challenging that I have ever experienced in over 30 years working in pain management.

While there is new scientific knowledge about persistent pain, this has not had much of an impact on patient care. For example, poorly managed acute pain increases the risk of developing persistent pain. At the end of life, a recent study showed that early intervention with palliative care not only improved quality of life and decreased depression, but also extended life for some. People with persistent pain often do not look as if they are in pain, yet health care providers frequently use an acute pain model to evaluate pain expression. New knowledge often conflicts with old beliefs that have been held, and old beliefs die hard. Clinicians need to learn that when it comes to pain management, “one size does not fit all” and individual assessment is crucial.

The problem of prescription pain medication misuse is another challenge. It is too early to know if abuse deterrent formulations of medications and new policy will make a difference. However, limiting legitimate access to medications for people with pain certainly will not solve the problems of addiction, misuse and diversion. We need to separate the treatment of the patient with persistent pain from the treatment of the person with an addiction disorder. Treatment is quite different for each. Treating the person with pain requires access to a variety of strategies that often include pain medications. Risk assessment and ongoing evaluation for misuse and addiction is an important part of all pain care when medications are part of the treatment plan. But, taking pain medications, as directed, to treat persistent pain should not be confused with having an addiction disorder. Severely limiting access to pain medications for everyone will not solve our national problem of addiction. Treating an addiction disorder requires very different strategies, the expertise of addiction specialists and policy that provides continuing care and support for people with this chronic illness.

Click here to read Part I of this two-part Clinical Roundtable.

Part II: What Are The Greatest Challenges Ahead?

In the year 2000, the Joint Commission on Accreditation of Healthcare Organizations released new standards for the assessment and management of pain in the facilities they accredit and certify. C. Richard Chapman, Ph.D., then the President of the American Pain Society, described this as “a giant step…a major leap forward”. A few months later Congress passed and the President signed a law that declared the ten-years beginning January 1, 2001 as the Decade of Pain Control and Research.

Charles E. Argoff, MD:

Charles E. Argoff, MD, is Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in New York. Dr. Argoff received his medical degree from Northwestern University’s Feinberg School of Medicine in Chicago, Illinois. He completed an internship in the Department of Medicine and a residency in the Department of Neurology at the State University of New York in Stony Brook and a fellowship in Developmental and Metabolic Neurology at the National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH/NINDS).

"What is your personal evaluation of the greatest challenges ahead, as we enter the next decade?"

We now know that in the past, we were advocating for better recognition of the need to adequately treat chronic pain. We probably underappreciated the complexity of its treatment and unexpected problems like side effects and aberrant drug-related behaviors, most notably, diversion of prescription pain medications. Also, currently, there are changes happening in the regulatory environment, but we don’t know the extent of them, and what their ultimate effect will be. The worst-case possibility is that regulatory changes will have a chilling effect on chronic pain management going forward into the next decade; specifically on the use of opioids for the treatment of chronic pain. It is likely that fewer clinicians will prescribe them if the steps they will need to take are too cumbersome. This will likely decrease patient access to medications that may be an appropriate component of their treatment plan. On the other hand, there is the possibility that having increased rules will give structure to primary care clinicians, and “liberate” them to prescribe in the way they believe is best for the patient.

As we move forward into the next decade, we need to teach all providers that chronic pain like all other chronic illnesses can be challenging because of lack of treatment adherence. We know that misuse of medication is a risk but we should have the knowledge and tools to help us make good decisions, so clinicians will feel educated and comfortable as they proceed. Clinicians have to learn that treatment of chronic pain, like treatment of diabetes, requires a rational, logical approach.

Economics and healthcare is another very important issue as we move forward. Many programs that offered a multidisciplinary treatment approach to chronic pain, that in the long run would potentially decrease use of medication alone, have closed because of poor reimbursement. At both the academic medical centers and in the community clinics, one can reasonably say that ultimately “money rules”. While the question is asked “what can you do to increase revenue to the health care system”, no one is studying how much more effective an integrated approach to chronic pain treatment is, in order to give payers the incentive to support this kind of treatment. We need to combine a scientific approach and clinical practice, in order to measure outcomes and develop best practices. Guidelines by themselves won’t do the job.

I think the future is now, and that this is a critical point in time in pain management. We cannot make treatment more individualized if we are going down the road of limiting choices. We may not only be facing having the rug pulled out from under us from prescribing opioids, but off-label prescribing, which is often a very important aspect of treatment planning may go away as well. Payers are sometimes quick to label what I would consider the “art of medicine” as experimental. In the future, economic forces will likely play an even larger role in how health care providers can use the art of medicine.

I hope that enough clinicians will get together to use evidence-based medicine practices effectively recognizing as well that there is insufficient evidence to make all treatment decisions and that studies used to create evidence based guidelines do not reflect the average patient in most practices. We truly need to reorient the discussion as the patients being studied in clinical trials are not usually representative of the average chronic pain patient in the doctor’s office. We need to do a much better job of focusing on the types of patients that primary care providers see in their offices every day to make a real difference.

Dr. Argoff is a member of the International Association for the Study of Pain, the American Academy of Pain Medicine, and the American Academy of Neurology, among other professional organizations. He serves on the editorial board of the Clinical Journal of Pain and as a reviewer for the Journal of Pain, Brain, JAMA, Archives of Physical Medicine and Rehabilitation, Journal of Musculoskeletal Pain, Journal of Pain and Symptom Management, and the Clinical Journal of Pain. He is Co-Editor of the Neuropathic Pain Section of Pain Medicine. Dr. Argoff has served as a guest editor for and published articles in the Clinical Journal of Pain and Current Pain and Headache Reports, among other peer-reviewed journals. He has written on many types of pain, including myofascial pain, spinal and radicular pain, and neuropathic pain. He has written on such treatments as topical analgesics, interventional pain management, botulinum toxins, and oral analgesics, and has contributed many book chapters as well. Dr. Argoff had an active role in the development of the diabetic peripheral neuropathic pain guidelines published in Mayo Clinic Proceedings, and he has contributed to other published neuropathic pain treatment guidelines. He is one of the editors of the recently published textbook Raj’s Practical Management of Pain, Fourth Edition. He is the co-author of Defeat Chronic Pain Now, a just published book for people with chronic pain. He has recently published the third edition of Pain Management Secrets.


Click he
re to read Part I of this two-part Clinical Roundtable.