Anyone who works in the medical field knows the toll chronic pain exerts on patients firsthand. Often
when you first see a pain patient, he or she already has a long list of providers he has seen and
treatments that have failed. He often brings to the visit not only a long and discouraging narrative but
an increasingly despondent emotional state.
Many chronic pain patients have stopped working and limited their life activities out of fear that their pain will worsen--a fear which ironically usually makes pain worse. They have become isolated and irritable and their family relations have become strained. Their eating and sleeping behaviors have often become dysfunctional and they may be catapulting toward depression, if they are not already clinically depressed. They have likely adopted verbal or non-verbal pain "behaviors" like sighing and grimacing which perpetuate the pain portrayal to others--and themselves. When you see such a patient, you often inherit the disappointing pain outcomes he has already endured and his increasing feelings of pessimism and skepticism.
Over 100 million Americans experience chronic pain and its treatment costs the U.S. $635 billion a year--compared with heart disease ($309 billion), cancer ($243 billion) and diabetes ($188 billion) (Institute of Medicine 2011). Chronic pain represent $11.6 to $12.7 billion a year in lost work days in (Institute of Medicine 2011) in the U.S. with many workers not returning at all. Yet, of the 27 institutes in the National Institutes of Health (NIH) not one is dedicated to pain.
That is why many clinicians who treat chronic pain are pleased to see the launch of a National Pain Strategy (NPS) earlier this year. A unified effort of the FDA, National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Departments of Defense and Veterans Affairs and the Agency for Healthcare Research and Quality, the advisory group, called the Interagency Pain Research Coordinating Committee (IPRCC), seeks to enact the Affordable Care Act goal of increasing "the recognition of pain as a significant public health problem."
Among IPRCC objectives are better education for pain patients about "effective approaches for self- care and pain self-management programs that would help them prevent, cope with, and reduce pain and its disability," a better patient understanding of the "benefits and risks of pain management options," greater "self-care interventions" for patients and greater use of coordinated, multidisciplinary care by clinicians.
While multidisciplinary care was the gold standard for decades, changing reimbursement patterns have resulted in excessive use of non evidence-based treatments, including the irresponsible use of opioids. Quite simply, there are no financial incentives for healthcare providers to promote multimodal and interdisciplinary approaches to pain management.
Many trace the multidisciplinary team concept to Tacoma General Hospital where John Bonica, an anesthesiologist, and his colleagues recognized that chronic pain patients needed more than a physician to improve their function in the 1940s. Dr. Bonica recruited a group consisting of John D. Loeser, MD, a neurosurgeon, Wilbert Fordyce, PhD, a psychologist, a physiatrist and physical and occupational therapists and sought to develop a bio-psycho-social model of pain management (IASP 2012).
"Because commonly used single-modality treatments often fail as first-line therapies for chronic pain, attention among leaders in the field has shifted to improving pain assessment and delivery of integrated, multimodal, interdisciplinary care that is effective and safe," wrote one of the National Pain Strategy report panels. Also needed, says the panel, is a "national educational campaign encouraging safe medication use, especially opioid use, among patients with pain."
The National Pain Strategy (NPS) recommendations are good news for pain patients and the clinicians who see them. They echo what I and my colleagues have learned in decades of practice-- that there is no "cure" or "quick "fix" for chronic pain but pain can be managed and patients achieve quality lives through multidisciplinary treatment.
This is an excerpt from Multidisciplinary Management of Chronic Pain: A Practical Guide for Clinicians available from Springer.
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