ATrain Education

 

Continuing Education for Health Professionals

DE: Substance Abuse, Chemical Dependency, and Drug Diversion

Module 2

The Treatment of Pain

Pain is part of the human condition; at some point, for short or long periods of time, we all experience pain and suffer its consequences. While pain can serve as a warning to protect us from further harm, it also can contribute to severe and even relentless suffering, surpassing its underlying cause to become a disease in its own domains and dimensions. . . .

 

Severe or chronic pain can overtake our lives, having an impact on us as individuals as well as on our family, friends, and community. Through the ages, pain and suffering have been the substrates for great works of fiction, but the reality of the experience, especially when persistent, has little redeeming or romantic quality. The personal story of pain can be transformative or can blunt the human values of joy, happiness, and even human connectedness.

 

Institutes of Medicine, 2011

 

Chronic pain affects approximately 100 million Americans, according to a 2011 Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education.

  • In 2011 at least 100 million adult Americans have common chronic pain conditions; this a conservative estimate because it does not include acute pain or children.
  • Pain is a significant public health problem that costs society at least $560 billion annually in direct medical costs ($261–$300 billion) and lost productivity ($297–$336 billion), (an amount equal to about $2,000 for everyone living in the United States). This cost of chronic pain is believed to be a conservative estimate because several populations were excluded, such as institutionalized and noncivilian populations (nursing home residents, military personnel and prison inmates), persons under 18, cost to caregivers in lost wages, and working persons over the age of 65 or under the age of 24.
  • In 2008 the cost to federal and state governments of medical expenditures for pain was $99 billion (including Medicare, Medicaid, the Department of Veterans Affairs, TRICARE, workers’ compensation, and others).
  • Recent CDC and National Center for Health Statistics (NCHS) data suggest substantial rates of pain from the various causes and that most people in chronic pain have multiple sites of pain. For U.S. adults reporting pain, loci include: severe headache or migraine (16.1%), low back pain (28.1%), neck pain (15.1%), knee pain (19.5%), shoulder pain (9.0%), finger pain (7.6%), and hip pain (7.1%). (IOM, 2011)

When Pain Becomes Chronic

Pain is a normal physiologic sensation that signals injury or disease. It serves a vital function, warning of the need for medical treatment. The International Association for the Study of Pain defines pain as

an unpleasant sensory experience associated with actual or potential tissue damage, or described in terms of such damage. . . . Pain is always subjective. . . . It is unquestionably a sensation in a part or parts of the body, but it is also unpleasant and therefore also an emotional experience. (IASP, 1994)

The Institutes of Medicine define pain this way:

Pain’s occurrence, severity, duration, response to treatment, and disabling consequences vary from person to person because pain, like other severe chronic conditions, is much more than a biological phenomenon and has profound emotional and cognitive effects. Pain can be mild and easily handled with over-the-counter medications; it can be acute and recede with treatment; it can be recurrent over months or years; or it can be chronic and debilitating, requiring almost constant attention and accommodation. (IOM, 2011)

Chronic pain is pain that persists, often for weeks, months, or years. The presence of chronic pain is a disease state in itself. When the pain’s warning function is completed, continued pain is an abnormal state. Its distinct pathology causes changes in the nervous system that often worsen. Its effects on a patient’s psychology and cognitive ability are significant, and include anxiety, depression, and anger.

Effective pain management is a moral imperative because the alleviation of suffering is the guiding star of medicine. Chronic pain prevention and management often require a comprehensive, interdisciplinary approach due to its diverse effects and the combination of biologic, psychological, and social factors. Chronic diseases, including chronic pain, involve many physical, cognitive, and emotional factors, but chronic pain often lacks reliable “objective” measures.

Knowledge of pain prevention and management is not always applied effectively; many people suffer pain needlessly. Chronic pain can result from age, genetic predisposition, or as part of a separate chronic disease, surgery, or injury. Healthcare providers must understand “pain is a uniquely individual, subjective experience” that depends upon many factors such as general health, genetic characteristics, previous pain experiences, the brain’s processing system, the context, and cultural and social background (IOM, 2011).

Trends in Pain Management and Prescribing

In past decades, concern about undertreatment of pain despite the numerous pharmaceuticals developed to treat it led to increases in prescribing of analgesics as part of a movement to treat pain, especially chronic pain, more aggressively. In 1998 the Federation of State Medical Boards (FSMB) released guidelines that supported the use of opioids for chronic, noncancer pain. This contributed to the increase in opioid prescriptions that followed. The Joint Commission, an accrediting body, then issued the Pain Standard, which evaluated healthcare organizations (including hospitals, ambulatory care centers, behavioral health, and home care) on the basis of their consistent, documented assessment of patients’ pain (ASAM, 2012).

The FSMB Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain has been revised twice since 1998, once in 2004 and again in July 2013. Key in the new model policy are the following points:

  • Many Americans suffer from chronic pain that is inadequately or ineffectively treated.
  • Since the 2004 revision, evidence for risk associated with opioids has surged, while evidence for benefits has remained controversial and insufficient.
  • Approximately one-fourth of all patients seen in primary care settings suffers from pain that interferes with their ADLs.
  • While under-treatment of pain exists, nevertheless chronic pain is often intractable and burdensome and current medical knowledge and therapies, including opioid analgesics, do not completely eliminate pain in most cases.

Furthermore, intractable pain is not always evidence of undertreatment, and may in fact result from over-treatment in procedures and medication (FSMB, 2013).

Balance is the goal in treating patients’ pain and preventing drug diversion, according to a Joint Statement from twenty-one health organizations and the Drug Enforcement Agency (DEA):

Preventing drug abuse is an important societal goal, but there is consensus, by law enforcement agencies, health care practitioners, and patient advocates alike, that it should not hinder patients’ ability to receive the care they need and deserve. . . . Undertreatment of pain is a serious problem in the United States, including pain among patients with chronic conditions and those who are critically ill or near death. Effective pain management is an integral and important aspect of quality medical care, and pain should be treated aggressively. (Joint Statement, 2002)

Primary care is where patients with pain usually go first, but these physicians rarely have the time to perform comprehensive patient assessments. Both providers and patients should be educated to understand that pain management must be tailored to each individual, which may take time (IOM, 2011).

Opioids are very effective in the treatment of pain. Their increased use is in part due to the pharmaceutical industry’s widely marketing opioids to physicians, and offering incentives for prescribing. In May 2014, two California counties sued five of the world’s largest narcotics manufacturers, claiming that these pharmaceutical companies engaged in a “campaign of deception” to boost sales of prescription analgesics such as OxyContin and thereby caused the national public health epidemic of prescription drug abuse.

The lawsuit alleges that the companies actively worked to expand their market by engaging in a dishonest campaign to encourage doctors to prescribe opioids for pain relief by hiring physicians to give speeches and write papers to encourage more liberal prescribing practices (Glover & Girion, 2014). A similar suit against five narcotics manufacturers was filed in June 2014 by the City of Chicago. The city sought damages and accused the drug companies of deceiving the public about the risks associated with the use of pain medications while overstating their benefits.

The University of Wisconsin Pain and Policy Studies Group received $2.5 million from narcotics manufacturers over the last decade. That pharmaceutical group was a significant force in the liberalizing of opioid analgesics for noncancer pain by helping to create “a body of ‘information’ that today is found in prescribing guidelines, patient literature, position statements, books, and doctor education courses, all of which favored drugs known as opioid analgesics” (Fauber, 2012).

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