Treating Pain in the Age of Opioid Addiction

By Lucy Berrington, MS

Fair warning: This article will not tell you how to treat pain in the age of opioid addiction. It may, however, validate your frustrations, offer some clues to what works and what doesn’t, and reassure you that efforts are underway to improve the options for and outcomes of pain treatment. Patients’ pain matters. And so does physicians’, whose pain about pain showed up starkly in a recent collaborative research process in Massachusetts.

Physicians joined patients and other stakeholders for a “human-centered” research investigation into how pain is currently assessed and managed, undertaken last year by Massachusetts Health Quality Partners (MHQP). “Clinicians in our workshops said, ‘I never get to talk about taking care of people with chronic pain, how much distrust and frustration there is, how inadequate I feel,’” says Barbra Rabson, president and CEO of MHQP, an independent nonprofit that measures and reports on health care information. “This is a key driver to burnout; we hear it time and again.”

The research, funded by Cigna, yielded five key findings:

Pain Is Poorly Understood

“We heard from clinicians saying, ‘I’m a diagnostic machine. When I can’t explain what’s going on, I’m much less sure of how to proceed. I don’t feel I have all the tools in the toolbox,’” says Rabson.

Even the available tools can be inadequate. The 10-point numerical scale for patients’ pain self-reports, for example, cannot adequately factor in the complex psychological and behavioral components of pain, such as fear and isolation — contributing to pain scores that may seem unconvincingly high to clinicians. In a small, hospital-based study reported at a conference, improved communication about pain assessment resulted in lower patient scores, contributing to earlier hospital discharge and reduced opioid prescribing, says Rabson — revealing a target for prevention-based improvement.

The multidimensional understanding of pain is a key insight of modern pain practice, and has been confirmed recently in functional brain imaging studies, says Daniel B. Carr, MD, MPH, professor of public health and community medicine at Tufts University School of Medicine and director of Tufts’ graduate program in pain research, education, and policy. “To look at pain only as the detection of tissue injury is only half of the picture. The other half is that pain as an experience is a distressing experience similar to when you’re abandoned or isolated.” A small, persuasive amount of literature describes the stigmatization of patients with chronic pain, says Dr. Carr, and patients’ depression and social withdrawal are barriers to self-advocating for treatment.

Pain Comes with Distrust

The context of the opioid epidemic is derailing patients’ and providers’ conversations about pain. “A big surprise for me was how painful this is for many of the PCPs,” says Rabson. One physician said, ‘Taking care of chronic pain patients is the most miserable part of my week.’ Another said, ‘It doesn’t take more than about two patients trying to get drugs off you that they don’t need before you’re distrustful of everybody.’”

Patients report that their pain has been repeatedly dismissed. The risks of under-treating pain may be overlooked. “I get lots of unsolicited and frequently heartrending emails from patients cut off from their medications suddenly because of the amount of fear around opioid prescribing,” says Dr. Carr. Untreated pain can raise the risk of suicide.

Systemic Barriers Impede Care

“The saying, ‘Every system is designed to get exactly the results that it gets’ couldn’t be truer than in this case,” says Rabson. Physicians and researchers report systemic challenges to clinicians’ ability to support patients in pain — challenges that include a lack of training, insufficient time with patients, and significant gaps in the medical literature. For example, patients respond to information about non-opioid treatments, says Dr. Antranig Kalaydjian, MD, a resident in pain management at St. Elizabeth’s Medical Center, “but it’s hard to find time in 15-minute consults to talk to patients about the evidence behind physical therapy.”

The CDC recommendations include commonsense protocols — taking a thorough history and screening for psychiatric risk — that are largely helpful and reflect prior, established consensus among clinicians treating pain, says Dr. Carr. But these, too, are undermined by structural barriers to best practice. Pharmacists report that patients filling their opioid prescriptions are sometimes under-informed; they may not know if their medication is an opioid, be naïve to drug interactions, or have unrealistic expectations of pain medications.

Insurance Coverage Is Limited

When pain specialists talk about the best practice in pain treatment, they describe multimodal pain treatment facilities that address pain as a complex biopsychosocial condition. Such centers offer a range of approaches in addition to medication, and individualized treatment plans that include behavioral, psychological, and functional assessments and interventions. Strategies include goal-setting and psychological trauma treatments, as well as physical therapy, acupuncture, or mindfulness, which may reduce or eliminate the need for pain medications.

But such facilities and specialists are scarce. Our health care system is oriented toward medical solutions. Insurance plans commonly do not reimburse adequately or at all for alternative pain management approaches, which are inherently difficult to evaluate and sometimes indirectly relevant. “If patients are more resilient, they do better managing their pain,” says Rabson. “If some of these therapies increase resilience, even if they don’t decrease pain, shouldn’t we be looking at that?”

Hope Gets Lost

Those crucial psychological pieces — setting goals, promoting empowerment and hope — are often missing from pain care. “Sometimes it feels like what I am doing most is bearing witness, honoring a patient’s difficult situation, and providing support and clinical empathy. This requires emotional energy and time,” says Stephen A. Martin, MD, associate professor of family medicine and community health at UMass Medical School, who participated in the MHQP research.

Next Steps in Pain

The next stage of the MHQP project will focus on developing tools for improving pain education, providers’ pain assessment, and patients’ resilience, and integrating relevant evidence into health plan coverage decisions. Health care organizations are keen to help test the new resources, says Rabson. “The opioid crisis is serving as a wake-up call to providers and the wider culture about how we can treat pain better,” says Dr. Kalaydjian. “Even the most ‘difficult’ pain patients are fellow creatures in suffering. Any difference you can make — and sometimes we can dramatically affect their quality of life and functioning — is immensely satisfying.”

Help Your Patients Ask the Right Questions