In this interview with IHI, former IHI fellow Dr. John Krueger, draws on his years of experience to consider the complicated issue of pain from the perspective of both patients and care providers.
Q: Why is it so important to address pain management?
We have real issues with pain in the United States and around the world. At least 100 million Americans suffer from chronic pain. The Institute of Medicine estimates that pain costs up to $635 billion a year in medical care and lost productivity. Pain of some form is diagnosed more often than diabetes, heart disease, and cancer combined. Despite the widespread use of opioids and other modalities, we have clearly not found a safe and effective global strategy to treat pain.
Q: What are some of the challenges involved in improving pain management?
One challenge is perceptions of pain. There are a host of cultural beliefs that influence how we think about pain and suffering that don’t necessarily have a lot to do with the physical, emotional, or cognitive sensations of pain.
Different societies form beliefs and expectations about how an individual or a clinician should address pain. A wonderful book called The Gift of Pain asserts that, without pain, you wouldn’t be aware that something might be wrong and might cause harm to you. Pain can be beneficial. It’s a vital feedback mechanism that is essential for survival, and yet pain is also unpleasant, and it is difficult to see any benefit when you’re the person suffering.
Pain has been described as a medical condition for centuries. Yet it is really the symptom of what may be a medical problem. By medicalizing pain as an illness, are we missing an important opportunity to help our patients solve the real problems for which they are seeking our help? By treating pain solely as a medical condition, especially outside the context of the biopsychosocial model, we might “solve” one problem and create others.
One example of this is when a clinician prescribes opioid therapy. In most cases, the patient takes the agent, and it works as it should to relieve some of the pain. Eventually the condition resolves as the body heals itself, and the opioid is discontinued.
But what happens when the pain does not resolve? What is the problem we are now trying to solve? Is it pain, or the condition? What happens if the pain gets worse? Does the physician increase the dose? Initially this strategy may have some benefits, but increased doses of opiates have some unintended consequences.
Another problem is that clinicians write the overwhelming majority of opioid prescriptions for chronic pain, but there is little evidence that taking opioids for non-cancer pain is safe or effective, especially at large doses. We now have thousands of accidental deaths each year in the community due to unintentional poisoning with opioids. Moreover, opioids are associated with tolerance, dependency, and in some cases addiction, non-medical use, and abuse. We should help and heal the patient who is in front of us, but we also need to treat the patient safely and effectively and guard against unintended consequences to them and to society as a whole.
Q: What are the keys to success for helping patients manage pain?
Teams that are successful look at the science, and are willing to learn what works for their patients. Effective clinicians and teams help to improve the health literacy and competency of their patients. They also communicate that they will consider the patient’s safety first and foremost, before an immediate quick fix. These clinicians and teams are generally willing to use what works as long as the treatments have a very low risk of harm to the patient.
We need more and better options for treating pain, but a lot of things can work. For example, there is evidence that indicates that acupuncture works for certain kinds of pain. There is also extensive evidence that therapeutic exercise can help alleviate most kinds of chronic pain. There’s also some evidence that chiropractic and osteopathic manipulative therapy works for certain conditions and pains.
The most effective teams ultimately teach the patient to self-manage their pain, typically with the lowest possible dose of medication. Most patients with chronic pain will tell you that they fear loss of control more than anything, so giving the patient control can be an important component of effective pain management.
I want to be clear. I am not suggesting that we should let patients determine what and how much they are prescribed. Instead, you describe the options that are safest, the limits, the pros and cons, how much each option would be expected to impact pain and function, and the consequences of each therapy on daily living. Whether it is an opioid, therapy, meditation, exercise, or other option, giving the patient the ability to weigh in on what they think they need to self-manage within the constraints of safety can be empowering and very effective.
Q: How do we find the right balance between addressing clinicians’ concerns about abuse, addiction, etc., while also preventing unnecessary suffering?
There is no simple answer. As a clinician you have to ask, “What are the factors contributing to this person’s pain?” In patients on opioids, we should ask why this person is taking or seeking an opioid. Are they afraid of withdrawal? Are they addicted? In some patients, we have to determine if they’re seeking substances for non-medical use. This occurs infrequently, but those who prescribe opioids for pain must consider it.
Everyone who takes opioids for long enough periods of time develops tolerance. In some patients, opioids can have long-term implications even with relatively short duration of use.
So, what do you do for the patient who says the only thing that will “work” is an opioid? You treated them with pills [before], but now the patient is saying the pills aren’t working like they did at first and they want a higher dose. You aren’t comfortable with that because you’re worried about harming the patient. You may be frustrated because you’re not sure what to do next.
To help reduce non-medical use and identify addiction, monitoring is required with urine or blood testing, pain contracts, refill policies, and database monitoring. However, the net result is often a relationship that does not feel based on trust.
As health care providers, we want to meet all our patients’ expectations, but sometimes that’s not the right thing to do. We can get into conflicts with patients when we become too adamant. Instead, it’s helpful to start by telling patients up front that not harming them or making their situation worse is your guiding, non-negotiable principle.
Q: The goal of various changes in the past 15-20 years – including patient survey questions about pain and the “Pain as the Fifth Vital Sign” initiative – was to address the inadequate management of pain. What improvements have you seen because of these efforts? What have been some of the unintended consequences?
Everyone has definitely become more aware of pain, and I think palliative care has blossomed to some degree, although not as much as we need. We’re starting to have better discussions about end-of-life care.
Unfortunately, some of the focus on pain has led to problems. For example, the WHO’s pain ladder was originally developed for cancer pain, but it was adopted for chronic pain even though the evidence wasn’t there for this use.
Also, some practitioners, health administrators, insurers, regulatory agencies, and others treated the effort to view pain as the "fifth vital sign" as a mandate. The prevailing attitude became that pain should be eliminated and controlled as a medical condition. For the better part of a decade and a half, this attitude got in the way of looking at a range of evidence-based outcomes, including pain, function, safety, and societal implications. Consequently, we were suddenly off to the races prescribing opioids.
Prescription drug overdoses now cause more deaths in certain segments of our population than car accidents. These medications are causing huge problems in society, ripping towns and families apart. It’s causing burdens on our legal and law enforcement systems. We’re going to have to come to terms with some of this on a societal level.
Q: How does the desire to make care more patient-centered – or the fear of the consequences of low patient satisfaction scores – influence how clinicians treat pain?
I am certainly hearing anecdotal reports that, unfortunately, some people are giving medications because they fear they’ll get a bad patient satisfaction score if they don’t.
Anecdotally, as an administrator I can tell you that I deal with a large number of patient complaints related to opioid reduction or discontinuation due to contraindications. While there are certainly a few individuals who are unreasonable or possibly suffering from addiction, the majority of patient complaints occur due to a breakdown in communication.
From the patient’s perspective, they may find the required monitoring and risk assessment process invasive, impersonal, and disrespectful. In a 20- to 30-minute visit, during which their primary care clinician may be trying to address three or four other chronic conditions, an acute condition, and type all the information into an electronic health record, the patient may feel as if no one really listened, or believed them, or really understood. Finding the right approach is a time-consuming process in most cases. Sometimes physicians can’t take that time, and most systems and reimbursement methods don’t accommodate spending more time. Frankly, sometimes patients don’t want to take that time either, at least initially, especially if they think that all they need is a prescription refill and that prescription medicines are always safe and have limited or no risks.
Learning how to address these kinds of issues with patients is challenging and exhilarating and has led to some very rewarding moments for me. There is no easy answer, but the struggle is worth it.
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