Education as an intervention for the chronic pain epidemic

A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

Chronic pain is a silent epidemic

Chronic pain is a significant public health burden, but one that is not talked about enough. In 2011, the Institute of Medicine estimated that approximately 100 million Americans suffer from chronic pain. But chronic pain is not just a national problem. The 2016 World Health Organization (WHO) Global Burden of Disease report named back pain as the leading cause of years lived with disability (YLD), or more simply stated, years not being able to live your best life. Chronic pain is a complex disease requiring access to physicians with the appropriate expertise in assessing and treating pain in a comprehensive interdisciplinary manner. Yet, education in the management of chronic pain is sorely lacking in medical schools, nursing schools, and allied health professional courses. Lack of access to appropriate treatment and expertise leaves patients with an inability to break out of the vicious cycle of increasing pain, functional limitations, physiological changes due to decreased activity and additional pain.

Ryan’s road to recovery

Ryan* was a high-functioning executive working for an international corporation in Southeast Asia. An unfortunate incident led to knee surgery leaving him with debilitating pain. After receiving a diagnosis of complex regional pain syndrome, Ryan was treated with medications to counteract pain experienced along the nerves, nerve blocks, and physical therapy. Despite several months of treatment, his condition did not improve and led to escalating doses of prescription opioids. Ryan ultimately decided to seek care in the United States and was evaluated at our clinic. After a thorough review of his condition, we mapped out a plan of care. Some initial interventions helped, and he was able to go back to work in Asia.

Unfortunately, Ryan had a relapse and his international physicians ramped up his opioids once again. Fed up and aware of the risk of addiction, Ryan returned to our clinic for an alternative solution to treat his pain. This time we discussed spinal cord stimulation, which uses a pacemaker-like device that replaces the pain with a more tolerable sensation, typically a tingling or massage-like feeling. We implanted the device in his lower back, attaching it to tiny wires located in his spinal canal. When Ryan felt pain, he was instructed to use a remote control to send signals to the painful area, which ultimately provided relief. Next, we enrolled him in a comprehensive physical and psychological rehabilitation program to meet his needs. Through education, encouragement, and perseverance Ryan was weaned off all opioids, lost 40 pounds and returned to work.

The management of chronic pain

Chronic pain is a complex disease which requires a multifaceted, multidisciplinary approach. Our patients expect to visit our clinic and receive a concrete diagnosis, plan of action, effective therapy, resolution of their complaints, and return to their normal lives. Often this is elusive in the field of pain.

Our patients entrust their lives and wellbeing to us. In this connected age, they have access to unprecedented amounts of information: some accurate and some not so accurate. They come in armed with printouts and ask many questions, expecting physicians to engage in shared decision-making and help them sort through the mounds of data they have amassed. Our goal should be to empower our patients through education and solicit their cooperation, ownership of their condition and compliance with an agreed upon plan for optimal outcomes.

The role of education

As any good educator will emphasize, teaching needs to be tailored to your specific audience. Hence, education of the public should focus on helping them to understand the concept of chronic pain as a disease and the prevalence of the problem. It is important to recognize that while most forms of chronic pain can be managed with appropriate treatment, a cure may remain elusive. Several risk factors have been identified that lead to the development of chronic pain. Some risk factors are non-modifiable while some can be controlled. For those that can be controlled, we should emphasize prevention strategies such as regular exercise, optimal nutrition and body weight, stress management, regular sleep and a positive mental attitude.

For patients who are already afflicted with the scourge of chronic pain, it is important to provide them with hope and to educate them about the underlying biology and complex interactions between their physical symptoms, their psychological well-being, and their social interactions and relationships. They should also be educated about the myriad of existing options for the management of their disease including self-management techniques (deep breathing, shifting focus away from pain, etc.), the importance of a graded exercise program, behavioral interventions (cognitive behavioral therapy, distraction, guided imagery, etc.), medical and interventional modalities (anti-inflammatory medications, nerve pain medications, nerve blocks, spinal cord stimulation, etc.) and complementary and alternative options (acupuncture, chiropractic therapy, massage therapy, herbal agents, etc.).

At the prelicensure level for medical, nursing and allied health students we should emphasize that regardless of what career path they choose, a segment of their patients will experience chronic pain as either their main problem or a coexisting condition. They need to be aware of the underlying biology, the complex interaction between the physiological underpinnings, the behavioral component and social ramifications of many chronic pain conditions. These students need to be prepared to assess and manage various chronic pain conditions and also understand when they should refer to a specialist. To manage the complexity of this disease, a multifaceted, multidisciplinary treatment plan formulated in a shared-decision making model, with the patient and their family, is essential for compliance and success.

Policymakers need to be educated about the social determinants of chronic pain, chronic pain as a disease, access to care and any additional information that will help them implement policies that will mitigate this epidemic and provide appropriate care for those already affected by the disease.

Given the magnitude of the chronic pain epidemic, it is essential that pain education is incorporated into prelicensure education through medical schools, nursing schools, and allied health education programs, as well as post-licensure education, including all residency programs and continuing medical education (CME), specially designed for primary care physicians and providers. Once the public, patients, policymakers and medical professionals are well-informed, we can more appropriately treat the complex disease of chronic pain and deploy opioids when and where clearly indicated with well-defined plans to taper, wean and dispose of any remaining medications.