Pain control requires multidisciplinary approach

September 1, 2013

Prevalence of chronic pain can add up to higher costs in mental-health and medical claims

Pain may not be visible to the eye, but the healthcare community is definitely seeing its effects. According to a 2011 report from the Institute of Medicine, chronic pain is estimated to affect approximately 100 million adults in the United States each year and carries an annual price tag between $560 billion to $635 billion in direct medical treatment costs and lost productivity. Those figures reach even higher when pediatric pain and acute pain are factored into the equation.

"It is an astoundingly prevalent problem," says Sean Mackey, MD, PhD, chief of the Division of Pain Medicine at Stanford University.

Aside from the significant cost implications, pain produces other hurdles for the healthcare community as well. It's a very complex condition that often requires a multidisciplinary approach to care.

"Pain is multidimensional in terms of what causes it, what alters it and what effects it, and there is no one magic bullet for most chronic pain problems," says Catherine Bushnell, PhD, scientific director of the division of intramural research at the National Center for Complementary and Alternative Medicine (NCCAM).

Healthcare experts say effective pain management is difficult because pain is not processed in just one area of the brain, typically has psychological components to it, and often requires different treatment methods for each patient.

"The reason why people tend not to appreciate it, is that pain is so different from other conditions in that you can't see it," says Allan Basbaum, professor and chair of the department of anatomy at the University of California San Francisco.

To improve patient outcomes and reduce overall costs, healthcare experts say there needs to be a shift in how providers, health plans and patients view pain management.

"It's going to require a national level plan to be able to do this because it is fundamentally a public health problem," Dr. Mackey says. "We need to get everybody on board understanding how to better prevent, assess, care for and research pain."

Acute vs Chronic Pain

In terms of pain management, not all pain is the same. Experts say some forms are more difficult to treat than others. For instance, acute pain, or pain that lasts for a brief period of time, often occurs post-operatively or after an injury and is typically the easier type of pain to address.

"It's a little more predictable and in most patients the pain will eventually resolve post-operatively," Bausbaum says.

Patients faced with acute pain usually respond to opioids or non-steroidal anti-inflammatory drugs, he says, which help control the pain until it subsides.

On the other hand, chronic pain-which is defined by the International Association For the Study of Pain as pain lasting more than three months-is often more difficult and costly to address.

"The mechanisms are very different and the treatment approaches are very different, and most importantly in the setting of persistent pain, the nervous system changes so that the brain and spinal cord of the patient with ongoing pain and ongoing injury is actually different from the patient who has acute pain," Basbaum says.

According to him, there are two major types of chronic pain. The first is persistent pain that is produced by a tissue injury, such as arthritis, some back pain or most cancer pain. The second, more complicated type of chronic pain, is neuropathic pain or pain that is caused due to a nerve injury either in the peripheral nerves or the central nervous system.

"Neuropathic pain poorly responds to opiates and does not respond to non-steroidal drugs so that you are forced into a whole different class because you are dealing with what I like to think of as more of a disease of chronic pain," he says.

Pain in Practice

Due to the staggering number of adults struggling with chronic pain each year, experts say the clinical manpower is simply not there to handle the patient load.

"There's not enough pain specialists to go around," Dr. Mackey says. "Most pain is actually managed in the home-most of it is self-managed."

He says the second line of defense is often primary care physicians who may address aspects of chronic pain as part of a patient's general health and wellbeing. Pain specialists may be needed if a patient isn't responding to conservative therapies or if they have a complex case of chronic pain.

Experts agree that due to the complex nature of chronic pain, multi-disciplinary approaches are often needed to effectively manage the disease.

"When you get into chronic pain it gets much more complicated, and you need to understand the whole person and treat the whole person. So, a good pain center would have psychologists working there plus your normal medical doctors working there so that they could treat everything," says Kathy Kreiter, executive director of the International Association for the Study of Pain.

While Mackey acknowledges that comprehensive coordination and care can carry a high price tag, he believes better pain management and improved outcomes will deliver savings in the long run.

"These patients are incredibly expensive," he says.

Joel Hyatt, MD, assistant regional medical director for the Southern California Permanente Medical Group in the Kaiser Permanente Medical Care Program, says the not-for-profit health plan has a large multi-specialty medical group that includes specialists in pain management, addiction medicine, physical medicine and rehabilitation at each of their medical centers.

"That really allows us the luxury of helping each other out when questions of pain management come up," Dr. Hyatt says. "Our primary care physicians know that if they have concerns or questions about an individual patient whose pain they may be managing that they may be having difficulty with, etc. we can easily call we don't even have to formerly refer a patient. We can call one of our colleagues and ask for help." 

The Southern California Permanente Medical Group also takes a comprehensive approach to pain management that could include cognitive behavioral therapy, acupuncture, medication or massage.

"Health plans should support what's needed for appropriate pain management, not just drugs," he says.

Dr. Hyatt says that while other health plans don't have the single multi-disciplinary provider group that they do, he believes it's important to involve physicians in the process when developing pain management policies and procedures.

"Physicians want to help their patients and physicians will be able to tell health plans what they can do and what may be getting in the way, what barriers are being created by health plan policies for example," he says. 

Reducing Opioid Abuse

Opioid use and abuse in the United States continues to be high, but due to the serious and costly implications of these medications, many in the healthcare community are trying to limit their use. What’s difficult is maintaining appropriate access for patients who need the treatment while curbing the access for those who show signs of addiction or illegal use.

According to the Centers for Disease Control and Prevention, the number of people who die from drug overdoses each year is three times higher than it was in 1990. They report that in 2008 more than 36,000 people died from drug overdoses and say that 14,800 of these deaths involved prescription pain killers. Prescription drug abuse and misuse was also responsible for 475,000 visits to the emergency room in 2009.

Research has shown that the risk of an overdose increases with increasing doses of opioid pain relief. For instance, a recent study led by Kate Dunn, PhD, and her colleagues found that persons receiving a dose of 100 mg per day or more had an annual overdose rate that was nine times higher than people who were receiving the lowest doses in the study.

Dr. Hyatt says this finding has helped direct the pain management policy at the Southern California Permanente Medical Group.

"Our main focus has been to try to manage pain effectively using all the modalities at hand, but to definitely try to avoid that ceiling of 100 or 120 milligrams of morphine or morphine equivalence per day," he says. "If we hit that our physicians know that's the red flag. That's the time the bell goes off that they should probably be consulting with one of our pain management specialists."

Dr. Hyatt says the medical group has tried to shift away from using opioid medications for non-cancer patients primarily because it's in the best interests of patients, but there are also some cost benefits from reducing their use.

"Our usage of these has gone down dramatically," he says. "They literally dropped by over 70%, so there have been millions of dollars in savings in drug costs without sacrificing appropriate pain treatment."

He says the opioids not only have abuse concerns, but research has also shown they aren't effective in treating some types of chronic pain such as migraines, fibromyalgia and lower back pain.

In the field, many physicians are also utilizing other methods of pain treatment. Scott Woska, MD,  is a physician at the Shore Orthopedic Group in New Jersey has had success using a cooled radiofrequency system to relieve pain for patients suffering from sacroiliac joint pain. Dr. Woska says the large joint is the source of back pain for about 20% to 25% of the patients they see and says the non-pharmacological treatment option has had successful results.

The treatment creates spherical lesions that encompass the nerve path and block the pain. Some patients receive the treatment once and experience pain relief, while others may need it repeated after 12 to 18 months.

"It may cost you $1,000 to $2,000 between the surgeon, and the facility and the equipment to do that once a year versus hundreds of dollars per month of medications, not to mention therapy," Dr. Woska says.

Reducing the use of painkillers has been effective in acute pain settings as well. Rita Hadley, MD, PhD,  general surgeon at Miami Valley Hospital in Dayton, Ohio, says she is able to reduce the amount of narcotics her patients use after surgery by implanting a special catheter that delivers a local anesthetic directly to the surgical site. 

"I definitely think that narcotics have a role in treating acute pain, but I also think that they shouldn't be the first line of therapy," she says. "We can maximize other modes of therapy especially in surgical pain that might allow us to get further along before they need narcotics or use less narcotics."

Dr. Hadley says using the pain pump not only reduces the amount of side effects patients often experience while on narcotics, but says it can also reduce readmission rates and number of days patients spend in the hospital.

"We have shown that you can save a lot of money," she says. "We had a hip fracture study that showed that our hip fracture patients that came into the emergency room, if they got a pain pump associated with a nerve block within the first 24 hours of coming into the emergency room, then the hospital saved $1,200 per patient by doing that because their pain control was so much better."

Alternative Medicine

Medication isn't the only way to treat chronic pain. Experts say some alternative therapies such as yoga, exercise, cognitive behavioral therapy or meditation have also have promising effects.

Bushnell says studies have shown that psychological processes can be just as powerful as medication when it comes to effectively managing pain. For instance, she says laboratory tests have shown that simply redirecting a person's attention away from the pain can be just as impactful as a standard dose of morphine.

"It actually has a very powerful effect, and we look at the brain and we see the pathways that are involved, so it's not just that the person feels the pain and just ignores it," she says. "It actually diminishes it."

A person's emotional state can also play a role in overall pain management, with more positive mindsets reducing pain she says. Healthcare experts say psychologists can be integral in providing chronic pain patients with coping mechanisms, support and ways to avoid depression.

Research has shown that patients struggling with all types of chronic pain, whether its back pain or arthritis, experience what Bushnell described as a premature aging of the brain where patients lose grey matter in the brain at a faster rate than their healthy counterparts.

Yoga could be one way to limit this effect. Bushnell says a study of healthy yoga practitioners found that those who practiced yoga long term had more grey matter than other healthy adults in the control group.

Yoga practitioners also had slightly higher pain thresholds and significantly higher pain tolerance levels.

"With particularly the mind-body therapies there is some evidence that they seem to tap into these processes that are important for modulating pain and they are important for maintaining the health of the brain," she says.

Basbaum says placebos have also been found to be effective; however, he says just because they can be effective doesn't mean a patient isn't experiencing real pain.

"Placebos work because pain is a psychological percept and so why shouldn't a psychological intervention be helpful," he says.

 

Jill Sederstrom is a freelance writer based in Kansas City