Pain management: Patient needs must come first

In 2015, pain continues to be a conundrum for patients, practitioners, pharmacists, caregivers, long-term facilities, and payers. Balanced pain management is a comprehensive approach to diagnosing, treating, and controlling pain. It can include physical therapy and rehabilitation, psychological counseling, social support and/or medications, plus interventional procedures depending on an individual’s needs. Yet, many of our patients are not getting the care and relief they deserve, whether they suffer from acute or chronic pain. Unfortunately, we know from surveys that an estimated 40% to 70% of patients with chronic pain are not receiving proper medical treatment.¹ Those with acute pain may face similar circumstances.

There are many complex reasons why patients are not getting adequate pain relief. Three important considerations are: reduced access to medications perceived to have a high cost; safety concerns, including the abuse, misuse, and diversion of opioids; and limited access to integrated pain management, such as physical medicine and rehabilitation, complementary care, and psychosocial counseling.

For the more than 100 million who suffer from chronic pain and untold millions with acute pain, access to appropriate, individualized pain management and clinical care is critical.^2,3 Equally important is the safe use of medications when they are prescribed.

As the population, especially the aging population, continues to grow, so will the national pain crisis. New strategies are needed to help improve access, outcomes, and medication safety.

Pain and the role of multimodal analgesia

One step in the right direction is to ensure hospitalized patients with acute pain have their pain resolved effectively and efficiently. If not treated effectively, acute pain can become chronic, and chronic pain patients use a substantial portion of healthcare resources.^4,5

Opioids are commonly prescribed for acute pain in the hospital setting. Although these drugs play an important role in the treatment of pain and are inexpensive in generic form, they can be associated with serious adverse events such as respiratory depression and bowel obstruction, as well as other complications such as sedation and dizziness leading to workplace accidents and falls. Ironically, hospitals may be over-relying on the use of opioids alone versus other pain management strategies, significantly increasing patients’ risk for adverse events and considerably driving up total costs with readmissions, longer stays, and additional care. According to data from a 2013 published study, total hospital costs for certain surgical procedures in which an opioid-related adverse drug event (ORADE) occurred were associated with a mean difference of $4707 more compared to surgical procedures without ORADEs. Length of stay associated with a surgical ORADE was 3.4 days longer than procedures without ORADEs.⁶

Multi-modal analgesia (MMA), the combination of two or more analgesics to attack pain from different pathways in the body, may offer patients effective pain management while minimizing opioid monotherapy. The Joint Commission recommends MMA as a strategy to help avoid accidental opioid overuse⁷ and numerous professional organizations such as the American Society of Anesthesiologists, American Society for Pain Management Nursing, the American Geriatrics Society and Society for Critical Care Medicine, consider MMA a best practice.

Despite medical community support for MMA, some formularies rely on generic opioids instead, because they are so inexpensive. To achieve the best outcomes for our patients, we need to pause, carefully assess individual patient needs, and prescribe the proper course of care at the appropriate time for each patient. We also must have the ability to prescribe what we think is the best approach for each patient.

Access to and safe use of opioids and alternative options

Opioids, when prescribed, have an important place in pain management, and ensuring their safe use is critical for individuals and society. But first, appropriate patients must have access, including those diagnosed with chronic pain. Patients also must have access to other management options, such as physical therapy and rehabilitation, psychological counseling, transcutaneous electrical nerve stimulation, and complementary approaches including acupuncture, therapeutic yoga, and biofeedback. It is critical that we discuss these options and ensure their availability to individuals in need.

Today, the pendulum seems to have swung too far on the side of caution in an attempt to reign in pain medication use. Although it is true in some cases that overreliance on opioids alone to manage pain has led to unanticipated, costly complications (including societal challenges related to misuse, abuse, and diversion), in other cases, those who truly need certain medicines or services find themselves with limited or no access because of stigma and safeguards aimed at unsavory “patients” (and unfortunately some clinicians). Sadly, for every doctor-shopping abuser, there are an untold number of patients suffering with debilitating pain caused by a serious disease or treatment consequence, traumatic injury, or major surgery. Take for example patients who experience HIV treatment-related neuropathy, postmastectomy-related pain, or chemotherapy-related neuropathy; many of these conditions require opioids or other medications.

For patients who are appropriately prescribed prescription pain medications, responsible use, storage, and disposal can help protect individuals, their families, and communities from harm.  This is where prescribers can play a vital role.

When prescribing certain pain medications, there must also be proactive discussion with patients that leads to a commitment to safely use, store and dispose of such medications, as part of the pain management plan. Prescribers also should be mindful to take appropriate steps to screen for potential abuse.  The Alliance for Balanced Pain Management offers tips for the safe use, storage and disposal of pain medication. 

Although pain relief is a national issue, we cannot forget the individual patient. As clinicians, our goal is not just to relieve pain, but to get patients functional and back to doing the things they normally do as safely and efficiently as possible. As such, we have a moral obligation that our patients have access to all available resources to alleviate their pain. 

This article was originally published in Formulary Watch, a sister UBM Americas publication.

References

1. National Institutes of Health. Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Draft Executive Summary. September 29–30, 2014.

2. Gereau RW 4th, Sluka KA, Maixner W, et al. A pain research agenda for the 21st century. J Pain. 2014;15(12):1203–1214.

3. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.

4. White PF, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology. 2010;112(1):220–225.

5. Gaskin DJ, Richard P. Appendix C. The economic costs of pain in the United States. In: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.  http://www.ncbi.nlm.nih.gov/books/NBK92521/. Accessed October 22, 2015.

6. Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother. 2013;27(1):62–70.

7. Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49.

Srinivas Nalamachu, MD, contributed this blog article to Formulary Watch as a guest author for the Alliance for Balanced Pain Management. He is president and medical director of International Clinical Research Institute Inc. and co-director, Pain Management Institute in Overland Park, Kansas. The Alliance for Balanced Pain Management is a diverse collecitve of 24 healthcare advocacy groups, patient organizations, and several commercial partners with a mission to advocate for balanced pain management by supporting organizations and individuals who share a common goal to reduce pain, reduce medicine abuse, and improve care.