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

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Part I: What Have Been the Greatest Achievements in the Past Ten Years? 

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 achievements in the past ten years as the Decade of Pain Control and Research draws to an end?"

Over the past decade a great deal has been accomplished. Health care providers now know that chronic pain is a disease state that can be treated, and that it is “epidemic” in occurrence. Ten years ago we taught that opioids should be available as needed for patients with cancer pain, but not necessarily if you were living with non-malignant chronic pain. Now we have learned through published evidence-based practice guidelines from the American Pain Society, that cancer pain and chronic pain can both be treated with opioids. We have also learned that there are other non-opioid medications that have shown good results in clinical studies of many pain diagnoses. Excellent comprehensive guidelines now exist for difficult diagnoses such as fibromyalgia and neuropathic pain, including non-opioid and non-pharmacologic recommendations. Expert approved websites offering information, education, and tools for providers and patients are plentiful now, and seem to be having an impact.

Even though we have made progress, we still have a lot more questions to answer. For example, we know how to effectively treat chronic pain due to failed back treatment, but we don’t necessarily know what will happen to this patient over the next ten, twenty, or thirty years. There has been a pitifully small amount of research done with patients who are receiving long-term treatment. Are we helping them or hurting them with pain medications? Should we encourage more use of Complementary and Alternative Medicine methods instead?

I also think that at the end of this decade, in spite of all of the progress that has been made, we may have actually taken a step backward for chronic pain patients, as we deal with the suggestion of limiting access to pain medications in the future. The “War on Drugs” and provider concerns about prescription pain medication abuse, misuse, and diversion, as well as provider liability and lack of adequate health insurance reimbursement, may have made it more difficult to find a clinician who is willing to assume the medical care for a chronic pain patient, especially if an opioid medication is the treatment of choice.

The concern about misuse of pharmaceuticals which has soared over the last three to four years has stopped us in our tracks; taking away from what we had achieved by having pain recognized as the fifth vital sign, and understanding that pain is as the patient describes it. Now all of the focus seems to be on risk mitigation and the conversation has changed. I am a spokesperson for several pain safety initiatives so I know that while pain treatment is important, we also have to protect the patient, family, and the community.

If the FDA’s Risk Evaluation and Mitigation Strategies for opioids (REMS) are done correctly, they can give a great boost to our attempts to provide educational opportunities for both patients and providers. But I believe that education is not enough. We need to increase utilization of tools such as the state prescription monitoring programs, and continue to implement risk reduction strategies such as universal precautions. If the part of REMS that limits access is draconian, we will need to tread very carefully to ensure proper balance between public safety and appropriate pain care access.

Part I: What Have Been the Greatest Achievements in the Past Ten Years? 

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 achievements in the past ten years as the Decade of Pain Control and Research draws to an end?"

We have accomplished a lot, but there is a very long way to go. Over the past ten years there has been an explosion in the knowledge of pain physiology and pathophysiology. Unfortunately, this information has not been widely disseminated nor adopted by many health care providers. Clinical practice is slow to change. One accomplishment is that clinicians have increased awareness of pain and there is more screening for pain as a routine part of care. But I believe there is still too much reliance on obtaining a number on a pain rating scale, and then not taking the next step to complete a comprehensive individualized assessment that leads to the development of a treatment plan. A pain rating by itself is just the beginning.

Certainly pain is more visible now in all health care facilities, including hospitals, long term care settings and in home care. The Centers for Medicare and Medicaid Services (CMS) are using quality measures to track how pain is managed in the facilities their programs cover. This information is publicly available and can be a very powerful tool to improve clinical practices.

In addition, there are an increasing number of professional organizations and advocacy groups recognizing the importance of identifying pain, and dedicated to improving the way pain is managed. For example, in the Commonwealth of Massachusetts, the Boards of Registration in Nursing, Physician Assistants, Dentistry and Pharmacy have all issued Advisory Rulings on professional responsibilities related to pain assessment and management. The rulings contain this language to describe untreated or inappropriately treated pain; “For the purposes of this Policy, the inappropriate management of pain includes non-treatment, under-treatment, over-treatment, and the continued use of ineffective treatment.”

One current challenge is balancing appropriate access to pain medication while preventing or reducing diversion and misuse of pain medication. It's easy to make restrictions to access, but as a result, I see a huge reluctance to treat persistent pain, and to use opioid treatment, even when a specialist recommends this as an appropriate course of treatment. In my work, across the country, I hear from prescribers who are reluctant to treat people with persistent pain. Stories about the diversion of pain medication make the news, but the stories of people with persistent pain who thrive and function well in the community while appropriately using medications for pain, does not make the news. This imbalance of coverage contributes to limits in access to medications when prescribers become fearful or refuse to consider prescribing opioids, even when they may be medically necessary and improve an individual's function and quality of life.

Another issue is access to specialty care. Some states require consultation with a pain specialist for patients with persistent pain, yet the availability of specialists is limited and waiting times for appointments are long.

I have been in the field of pain management since 1978 and this may be the mostchallenging time we have had, as we try to find the correct balance of treating pain well and balancing safety and risk. I worry that care for many individuals with pain is not evidence based, but rather driven by fear, fueled by lack of education regarding pain assessment and management and what is over-publicized in the news. A Risk Evaluation and Mitigation Strategy (REMS) for most opioids is still an unknown. I will need to see what it looks like before I can assess its impact, but one concern is that it will further reduce access to the legitimate use of opioids for pain management. Hopefully, REMS will be across the entire class of opioids and not just for long-acting formulations and will not be so restrictive that providers simply will refuse to prescribe rather than go through the REMS process. An effective REMS should assist the person with pain to get the help they need, allow them access to medications in a timely manner, and not be another reason that a health care provider will be reluctant to prescribe what may be a very appropriate and effective treatment for some patients.

Part I: What Have Been the Greatest Achievements in the Past Ten Years? 

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). (continued below)

"What is your personal evaluation of the achievements in the past ten years as the Decade of Pain Control and Research draws to an end?"

There has been tremendous progress in the past decade in understanding that there is a critical need to do a better job in treating pain. However, this increased awareness has not led to increasingly better outcomes. A great many questions have been raised that still need to be answered in the future. Among them are questions such as what should be the role of interventional treatments in managing chronic pain, how can multimodal therapy help to improve outcomes, what qualifies someone to be considered a pain “specialist”, and what do primary care providers need to know to do a good job treating pain.

The fact is that most pain is treated in the primary care provider’s office. The “good” part of this is that as part of an increased level of awareness, primary care providers have been asked to play an increasingly significant role in the management of chronic pain. This leads to the possibility that primary care providers will work in collaboration with pain specialists. Unfortunately, how it plays out in reality differs from region to region, based on skill sets and availability of pain experts for consultation. What is “not good” is that the people who often have to address this problem often don’t have the appropriate skill set to do the job, and need additional training and education in order to do so.

In some ways, raising awareness of the problem of untreated chronic pain has opened “a can of worms”, and I don’t think the explosion in the number of guidelines on this topic has actually affected the care of the patients in many cases. Some primary care providers dorecognize that there are now many choices for pain treatment and procedures that should be followed, but still many patients are not given choices, and compliance to clinical guidelines may be low at the primary care level.

Although there may not have been significant clinical advances in chronic pain management over the last decade, in my opinion, there also have been tremendous advances in the basic sciences that have contributed to our understanding of chronic pain. These would include recognizing how acute pain that is poorly treated often becomes chronic pain, and why chronic pain is so different from acute pain. I believe that due to these advances, chronic pain is now better understood and recognized as a disease or disorder of the nervous system, rather than just a set of symptoms. But we are still challenged with trying to identify what we do know from what we don’t know, so we can select the best treatment that is tailored for the individual patient.

In the previous decades, when the cry arose for the need to treat cancer pain and chronic pain better, we may have underappreciated the complexity of pain, attempted to increase symptomatic treatment, and did not anticipate problems like the ones we are seeing now, like long-term side effects of chronic opioid therapy and the problems associated with aberrant drug-related behavior, especially drug diversion.

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.