An independent panel convened by the National Institutes of Health (NIH) has concluded that individualized patient care is needed to better treat the estimated 100 million Americans who suffer from chronic pain. The panel recommends more research and development of multidisciplinary treatments for pain patients, who are being treated by a “dysfunctional” health care system.
“Persons living with chronic pain have often been grouped into a single category, and treatment approaches have been generalized with little evidence to support this practice. Chronic pain spans a multitude of conditions, presents in different ways, and requires an individualized, multifaceted approach.,” said David Reuben, MD, panel chair and professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles.
“We have inadequate knowledge about treating various types of pain and how to balance effectiveness with potential harms. We also have a dysfunctional health care delivery system that promotes the easiest rather than the best approach to addressing pain.”
In September, 2014 the NIH held a workshop, “The Role of Opioids in the Treatment of Chronic Pain,” that included a panel of 7 experts and featured more than 20 speakers.
In a subsequent review the panel looked at the long-term effectiveness of opioids, the safety and harm of opioids, the effects of different opioid management strategies, and the effectiveness of risk mitigation strategies.
A summary of the panel’s final report was published this week in the Annals of Internal Medicine.
As in previous government studies, the panel used the term “epidemic” to describe the increased use of opioids, which has led to a “striking increase” in overdoses and treatment for addiction to prescription painkillers.
But the panel also made an effort to address issues from a patient perspective.
“Health care providers, who are often poorly trained in the management of chronic pain, are sometimes quick to label patients as ‘drug-seeking’ or as ‘addicts’ who overestimate their pain. Some physicians ‘fire’ patients for increasing their dose or for merely voicing concerns about their pain management. These experiences may make patients feel stigmatized or feel as if others view them as criminals and may heighten fears that their pain-relieving medications will be taken away,” the report states.
The panel found evidence that 40% to 70% of patients with chronic pain do not receive proper medical treatment, with many being over treated or undertreated. It estimated that about 5 to 8 million Americans use opioids for long-term pain management, although there is “scant” evidence on the safety and effectiveness of long-term opioid use.
Also lacking, according to the panel, is evidence about the value of many risk mitigation strategies, including patient contracts, urine drug screening, and pill counts.
“Clearly, there are patients for whom opioids are the best treatment for their chronic pain. However, for others, there are likely to be more effective approaches,” said Reuben. “The challenge is to identify the conditions for which opioid use is most appropriate, the alternatives for those who are unlikely to benefit from opioids, and the best approach to ensuring that every patient’s individual needs are met by a patient-centered health care system.”
The panel identified several barriers to implementing patient-centered care. Many physicians don’t have the tools or the training to assess patient measures of pain, quality of life, and adverse outcomes. Many insurance plans also don’t cover nonpharmacologic options, such as physical therapy, behavioral therapy, and complementary and alternative medicine. In addition, some plans do not offer effective non-opioid drugs as a first-line treatment for chronic pain, which limits a doctor’s ability to explore other avenues of treatment.
To address knowledge gaps, the panel cited a need for more research on pain, multidisciplinary pain interventions, the long-term effectiveness and safety of opioids, as well as opioid management and risk mitigation strategies. The panel also recommended the use of electronic health databases to help healthcare providers make pain management decisions.