The emotional, financial, and societal cost of dealing with chronic pain is exorbitant. Patients are desperate for relief. Providers are desperate for a broader range of effective, reimbursable treatment options. And everyone is desperate for solutions that don’t wind up doing more harm than good.
Asked how the nation is doing in addressing this complex issue, Bob Twillman, PhD, FAPM, executive director of the American Academy of Pain Management didn’t mince words. “Very badly … that’s how we are dealing with it,” he stated.
Scope of the Problem
“The Institute of Medicine put out a report in 2011 saying at least 100 million adult Americans have chronic pain,” said Twillman, who holds a doctorate in Clinical Psychology from UCLA and has spent decades working in pain management and palliative care. He noted that figure does not include those in the V.A. system, children, or individuals in long-term care facilities.
He added the report – Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education & Research – also estimates chronic pain costs the United States more than $600 billion annually in medical treatments and lost productivity. “Both the number of people and the amount spent is greater than heart disease, cancer and diabetes combined,” Twillman said.
Seeking Middle Ground
“Most people who have chronic pain are being prescribed some type of medication, often opioids. The others are left to ‘tough it out,’” Twillman said. “It’s just not the right way to approach the problem on either end of the spectrum.”
He added, “The middle ground is what we used to do in the 1990s – multidisciplinary, multimodal, integrative care for people in pain.”
However, the practice of medicine has undergone significant changes since that time period. Twillman noted most pain management isn’t provided by pain specialists but rather is addressed in the primary care setting, which doesn’t lend itself to long, complex appointments.
“To effectively treat someone with chronic pain takes much longer than 15 minutes,” he noted. “I’m fond of saying every patient is an n=1 experiment. Every patient is different. You have to take patients where they are and figure out the best solution for them … and again, you can’t do that in 15 minutes.”
There are a number of reasons why prescription therapy is the first … and quite often only real … line of treatment for chronic pain. Although opioids aren’t advertised, patients see ads for other medications promising a quick fix for any number of problems and want that same type of solution for their debilitating pain.
Twillman said another issue is that most primary care physicians are inadequately trained to treat pain so they often don’t know what else to do other than write a prescription. And those who do push for a multimodal solution often run into a brick wall with services either not being available (particularly in rural regions) or not being covered.
The Coverage Gap
Twillman said that based on evidence, there are five key non-pharmacological therapies that the Department of Defense and the V.A. have said every veteran and active military member should have access to when dealing with pain. “Of those, only one is covered to a limited extent by Medicare,” Twillman noted.
The five are chiropractic and osteopathic manipulation (which is partially covered depending on diagnosis), acupuncture, massage therapy, biofeedback, and yoga. While some commercial carriers do offer limited coverage, many follow Medicare’s lead. “We are beginning to push them on the issue,” Twillman said of advocating for everyone to cover these therapies as first-line options or adjunct care.
While physical therapy is included in most plans at some level, Twillman said the coverage is rarely adequate, and the co-pays are often so high that patients forego sessions. In addition, he noted, depression is highly associated with chronic pain so many patients should be referred to a behavioral health provider, as well.
The Tipping Point
“Every message that’s coming out now says that all of these other things should be done before a prescription is written,” he said. Twillman, who also serves as chair of the Prescription Monitoring Program Advisory Committee for the Kansas Board of Pharmacy, added new guidelines and peer-reviewed articles edge society closer to the tipping point when it comes to embracing a truly integrated approach to pain care.
His hope is that if consumers, government agencies and providers all demand access and reimbursement for a greater range of treatment options, then the healthcare industry might gain traction in changing how pain is managed.
To a large extent, Twillman added, changing the narrative is going to depend on those in pain. “We have to do a much better job of educating patients and motivating patients to do a better job of taking care of themselves,” he said.
Twillman also agreed it was a necessary, although difficult, task to find balance while standing on the edge of the tipping point. “The problem here is we’re really wrestling with two very complex, large-scale problems – prescription drug abuse and the problem of chronic pain.”
He pointed out laws created to restrict access to opioids also have consequences. “Those same laws are causing people who have a legitimate need for medications not to be able to get them. I’m afraid that problem is going to get worse before it gets better,” he said. “When you try simple solutions to these complicated problems, that’s when you get negative unintended consequences, and that’s what we’re seeing here.”
Ultimately, Twillman said, it is going to take collaboration across many sectors and disciplines, combined with great will, to find the right balance in addressing this growing national issue. “You have to have a complex solution to a complex problem.”
RELATED LINKS:
Relieving Pain in America Report Brief
American Academy of Pain Management
