There has been greater recognition over the past several decades of the pervasiveness of poorly assessed, poorly treated chronic pain, culminating recently in an Institute of Medicine report quantifying this healthcare issue. Evidence also suggests that the quality of and access to assessment and treatment of pain are poorer for racial and ethnic minorities. “This is a very large public health problem,” says Perry G. Fine, MD. “The issue has become even more important because of its concurrent overlap with the liberalization of prescribing patterns for opioid analgesics to treat chronic, non-cancer pain.”
Chronic Pain is a Costly Problem
Well over 100 million people in the United States are living with chronic pain that has some debilitating effect on their daily lives, costing society over $600 billion a year in direct medical costs and lost productivity. According to the American Pain Foundation, pain affects more Americans than diabetes, heart disease, and cancer combined (Table). The duration of pain in adults aged 20 and older who report having pain is longer than 1 year for 42% of patients (Figure). As these health and economic tolls have made their mark, they have exposed training gaps for healthcare professionals in recognizing and treating chronic pain adequately.
“With some additional training and by adopting well-established practice guidelines, the risks of abuse can be managed and limited for both patients and physicians.”
“We have not established a systemic approach to comprehensively prevent and treat chronic pain,” says Dr. Fine, “and comorbid psychiatric disorders can further complicate issues of treatment selection and adherence. Physicians are doing their best to return their pain patients to optimal health and optimal function. One of the easiest tools they have appears to be opioid analgesics. They’re highly efficacious in the short run and highly versatile, but they have serious problems attached to them with long-term use if these patients are not monitored well. The crux of the issue is how to treat, monitor, and manage chronic pain most appropriately without exacerbating potential issues of substance and chemical dependence (diversion, abuse, morbidity, and mortality) and without adversely restricting access to those drugs for patients who have appropriate and indicated needs for them.”
Although the parallel and occasionally overlapping public health quandaries of poorly treated chronic pain and prescription opioid abuse are visible and clearly present, their specific issues are only just being identified. Specialized education, including continuing medical education, and responsible prescribing guidelines continue to emerge. The hope is that these initiatives will alleviate pressure on physicians to automatically prescribe powerful analgesics when alternative treatment methods might be necessary. “The heavy focus on prescription drug abuse has created a great distraction from other things we can and should be doing to treat chronic pain,” Dr. Fine says. “Physician concern about opioid abuse can lead to undertreatment of chronic pain. However, with some additional training and by adopting well-established practice guidelines, the risks of abuse can be managed and limited for both patients and physicians.”
Important Principles in Managing Chronic Pain
According to Dr. Fine, a key principle in managing chronic pain is to establish a truly professional relationship with patients. “This begins with a total history and physical examination, corroborative laboratory and imaging studies, or collateral medical records from other practitioners,” he says. “Know who you’re dealing with. Assess the social context of patients by finding out who they live with, their potential medical and social risk factors if a trial of opioid therapy is being considered and is appropriate, and how patients have historically handled other drugs of abuse.”
A formal risk assessment is another important consideration. Following a formal pain assessment and a diagnosis, physicians can determine the safest, most effective approaches to treatment. This can also lead to considering less risky alternatives to opioid analgesics. Dr. Fine says if a trial of opioid therapy emerges as the only way to move patients forward in terms of function, sleep- and pain-related mood disturbances, and work and social restriction, then the key is to determine how much potential risk is there from exposing this person to opioids. “Moderate- and high-risk patients clearly require a different style of management than low-risk patients,” he adds. “Physicians need to determine whether the structure of their practice and their individual skill set have the means to manage patients throughout that spectrum of risk. The vast majority of people with chronic pain are being managed in the community by healthcare professionals who aren’t fellowship trained, board-certified pain medicine experts. This means that primary care and emergency physicians must step up their skills in order to manage more moderate- and high-risk patients.”
Readings & Resources (click to view)
Chapman CR, Lipschitz DL, Angst MS, et al. Opioid pharmacotherapy for chronic non-cancer pain in the United States: a research guideline for developing an evidence-base. J Pain. 2010;11:807-829.
Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.
Leverence RR, Williams RL, Potter M, et al; on behalf of PRIME Net clinicians. Chronic Non-Cancer Pain: A Siren for Primary Care – A Report From the PRImary care MultiEthnic Network (PRIME Net). J Am Board Fam Med. 2011;24:551-561.
Snidvongs S, Mehta V. Recent advances in opioid prescription for chronic non-cancer pain. Postgrad Med J. 2011 Jul 1. [Epub ahead of print].