ATrain Education

 

Continuing Education for Health Professionals

WV: Best Practices for Prescribing Controlled Substances and Preventing Drug Diversion, 3 units

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.

 

Institute of Medicine, 2011

 

The National Institutes of Health, National Center for Complementary and Integrative Health (NCCIH), reports the following statistics about chronic pain in the United States:

  • About 25.3 million U.S. adults (11.2%) had pain every day for the previous 3 months.
  • Nearly 40 million adults (17.6%) had severe pain.
  • Individuals with severe pain had worse health, used more healthcare, and had more disability than those with less severe pain.
  • The annual economic cost of chronic pain in the United States, including both treatment and lost productivity, has been estimated at nearly $635 billion. (NCCIH, 2018)

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, 2012)

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. In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to opioid pain relievers. 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 (Zimmerman, 2017).

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. The model policy features the following key 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 activities of daily living.
  • 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. On January 1, 2018 The Joint Commission implemented a new and revised pain assessment and management standards. The new standards, which revise the original standards established in 2001, state that hospitals must:

  • Establish a clinical leadership team
  • Actively engage medical staff and hospital leadership in improving pain assessment and management, including strategies to decrease opioid use and minimize risks associated with opioid use
  • Provide at least one non-pharmacologic pain treatment modality
  • Facilitate access to prescription drug monitoring programs
  • Improve pain assessment by concentrating more on how pain is affecting patients’ physical function
  • Engage patients in treatment decisions about their pain management
  • Address patient education and engagement, including storage and disposal of opioids to prevent these medications from being stolen or misused by others
  • Facilitate referral of patients addicted to opioids to treatment programs. (Joint Commission, 2018)

NCCIH is part of the National Institutes of Health Pain Consortium, which coordinates pain research across NIH. NCCIH-supported studies are helping to build an evidence base on the effectiveness and safety of complementary modalities for treating chronic pain. The scientific evidence suggests that some complementary health approaches may help people manage chronic pain (eg, mindfulness-based interventions, hypnosis, canabinoids (NCCIH, 2018).

. . . The amount of opioids being prescribed by our nation’s doctors, dentists, and nurses is excessive. While opioids offer relief to many patients with pain and should remain an available and acceptable option for pain management when medically indicated, it is clear from prescribing data and related addiction treatment admission and overdose death data that the medical community has over-relied on opioids to treat pain.

 

Letter to Chris Christie, Chair
President’s Commission on Combating
    Drug Addiction and the Opioid Crisis
ASAM, 2017

Opioids are very effective in the treatment of acute pain. The International Association for the Study of Pain issued a statement in February 2018:

Opioids are indispensable for the treatment of severe short-lived pain during acute painful events and at the end of life (eg, pain associated with cancer). Currently, no other oral medication offers immediate and effective relief of severe pain. Although opioids can be highly addictive, opioid addiction rarely emerges when opioids are used for short-term treatment of pain, except among a few highly susceptible individuals. For these reasons, IASP supports the use and availability of opioids at all ages for the relief of severe pain during short-lived painful events and at the end of life. IASP’s 2010 Declaration of Montreal states that access to pain management is a fundamental human right. In some cases, there is no substitute for opioids in achieving satisfactory pain relief. (IASP, 2018)

Widespread prescribing of opioid analgesics for chronic pain is controversial. Their increased use is in part due to the pharmaceutical industry’s widely marketing opioids to physicians and offering incentives for prescribing. “Between 1996 and 2002, Purdue Pharma funded more than 20,000 pain-related educational programs through direct sponsorship or financial grants and launched a multifaceted campaign to encourage long-term use of [opioid painkillers] for chronic non-cancer pain” (Lopez, 2018). Purdue provided financial support to the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, The Joint Commission, pain patient groups, and other organizations. These groups advocated for more aggressive identification and treatment of pain, especially prescription opioids (Lopez, 2018).

U.S. cities, counties, and states have filed lawsuits against 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 lawsuits allege 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. In May 2018, six more states announced suits against Purdue Pharma, the creator of OxyContin, bringing the total number of lawsuits that have been filed across the United States against opioid makers and distributers to hundreds. Lawsuits allege that pharmaceutical makers claimed that concerns about the potential for opioid addiction were “opiophopia” and directly and aggressively marketed to doctors through videos, pamphlets, and other materials, to foster the idea that opioids were safe and effective, persuading doctors to prescribe more of the drugs (Lopez, 2018).

While some lawsuits have been settled and some executives have been convicted for their involvement in the opioid epidemic, opioid companies reject the argument that they have carelessly fueled the current crisis (Lopez, 2018).

Even with the increased awareness of the opioid epidemic, prescribing remains high. In 2016 prescribers wrote 66.5 opioid and 25.2 sedative prescriptions for every 100 Americans (CDC, 2017a). Data show that prescribing varies widely from county to county. In 2015, 6 times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing counties. County-level characteristics, such as rural versus urban, income level, and demographics, only explained about a third of the differences. This suggests that people receive different care depending on where they live (CDC, 2017c).

Some characteristics of counties with higher opioid prescribing:

  • Small cities or large towns
  • Higher percent of white residents
  • More dentists and primary care physicians
  • More people who are uninsured or unemployed
  • More people who have diabetes, arthritis, or disability (CDC, 2017c)

In 2017 FSMB issued Guidelines for the Chronic Use of Opioid Analgesics. The guidelines may apply most directly to the treatment of chronic pain, however many of the strategies mentioned in the 2017 guidelines are also relevant to responsible prescribing and the mitigation of risks associated with other controlled substances in the treatment of pain.

The diagnosis and treatment of pain is integral to the practice of medicine. In order to implement best practices for responsible opioid prescribing, clinicians must understand the relevant pharmacologic and clinical issues in the use of opioid pain medications and should obtain sufficient targeted continuing education and training on the safe prescribing of opioids and other analgesics as well as training in multimodal treatments (FSMB, 2017).

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