Tag Archives: pain

Alternatives to Opioids for Pain Management

One of the areas of focus on Out Front Ideas with Kimberly and Mark has been addressing chronic pain without opioids. The workers’ compensation industry’s approach to chronic pain has historically been trying drugs and other medical procedures first. Then, if the pain has not subsided or has worsened, we look for psychological factors. If we truly want to help injured workers in pain and prevent opioid abuse and other unnecessary measures, we need to reverse that protocol. To learn more, we spoke with two of the nation’s most highly respected pain management experts, who gave us great insights into the experience of pain, how it can be best treated and non-pharmaceutical ways to treat pain.

Beth Darnell is a clinical associate professor in the division of pain management at Stanford; a clinical pain psychologist at the Stanford Pain Management Center; an NIH-funded scientist doing research on psychological treatment for chronic pain; one of the co-chairs of the Pain Psychology Task Force at the American Academy of Pain Medicine; one of the co-authors of the 2017 Chronic Pain Guideline updates from the American College of Occupational and Environmental Medicine; and author of multiple books on the subject: “Less Pain, Fewer Pills” and “The Opioid-Free Pain Relief Kit” — both written for patients. Dr. Darnell also recently co-published a research paper on The JAMA Network titled “Patient-Centered Prescription Opioid Tapering in Community Outpatients with Chronic Pain”

Dr. Steve Stanos is the medical director of pain management services for the Swedish Medical System in Seattle and runs the pain services for five hospitals in the system; the director of Occupational Medicine Services at Swedish; the president of the American Academy of Pain Medicine; and the medical director for myMatrixx. He was also a reviewer for the CDC’s Guidelines for Opioid Management and was involved in the National Pain Strategy.

Myths and Facts

Many of us have preconceived ideas about pain — what it is and how it should be treated. Unfortunately, many of these ideas are misconceptions and have led us to where we are today.

We think of pain as solely a physical experience. But our experts explained that pain is really a negative sensory and emotional experience. Psychology is an integral part of the pain experience, and, if we ignore that, we are not adequately addressing an injured worker’s pain.

Pain is very helpful in alerting us to situations where our bodies are at risk. If you put your hand on a hot stove, for example, the pain signals your brain to remove your hand. However, that does not work well for chronic pain when the continuing pain alert does not help us. Instead, it causes us fear and stress, which can actually exacerbate the pain. Those fears and stress are what we need to address in injured workers with chronic pain.

Another misconception is that people in pain are powerless to do anything about it and are at the mercy of drugs or other medical procedures. That simply is not true. There are teachable skills patients can use to assuage their own pain. These are learned skills.

See also: Is There an Answer to Opioid Crisis?  

We need to help injured workers understand and deal with the psychology of their pain experience up front, instead of waiting until the claim deteriorates. Medical providers, payers and others involved in a claim need to be aware of that and work with the injured worker to empower him or her to reduce their fears and stress and, in doing so, reduce their pain.

That leads us to another misconception — that dealing with the psychology of pain requires a specialist for extended sessions. Actually, non-behavioral health individuals can teach valuable skills to help cope with pain.

Again, this should be done early in the claim process for the best outcomes. The best predictor of outcomes in a pain program is early intervention with psychosocial factors. We need to have an early emphasis on behavioral health.

Yet another falsehood is that using drugs and medical procedures first is better for the patient because it does not assume he or she has any psychological issues. Instead, we are missing the elephant in the room, and, when the injured worker is finally sent for psychological intervention, it can be demoralizing. It sends a message to the injured worker that he or she is a failure and that the pain is all in his or her head. It does a terrible disservice to the injured worker.

We asked our experts whether all patients in chronic pain need psychological intervention. The answer was, yes, anyone in chronic pain can benefit from some level of behavioral intervention. That does not mean long-term, expensive, one-on-one treatments with a trained psychologist. Again, there are teachable skills to deal with chronic pain. The focus is on changing behavior.

Non-Pharma Pain Treatments

There are a variety of programs to help people deal with pain, many of which are based on cognitive behavioral therapy (CBT). This short-term treatment is goal-oriented and takes a practical approach to problem solving by changing patterns of thinking and behavior. Doing so helps change the way patients feel.

CBT is considered the gold standard of psychological treatment for chronic pain. It teaches concrete information and skills with action plans to move forward. It helps in creating care pathways that promote organized and efficient patient care based on evidence-based medicine. It helps patients become engaged and active in their own treatment so they rely on themselves more than the medical system.

Patients can learn the skills of behavioral health principles through classes and videos as well as by talking with therapists and others. Again, it is something anyone in pain can and should learn — not just those who are profoundly depressed or have other, more serious psychosocial issues. It is active management of pain.

Some newer treatments include mindfulness training, acceptance and commitment therapy and chronic pain self-management. These are all based somewhat on CBT, although not necessarily on pain management. Acceptance and commitment therapy trains you to stay focused in the moment so you do not react to pain. Negatively reacting to pain can be more distressing than the pain itself.

These programs teach people how to self-soothe. They also help establish meaningful goals and the steps to achieve them so people are not stuck in a passive mindset about their pain.

Functional restoration programs incorporate many of these aspects and can also be great, not only for at-risk patients already struggling with chronic pain, but also for early intervention. These programs have been around for years and typically involve physical and occupational therapy, psychology, relaxation training, exercise and vocational rehabilitation. The cost is fairly inexpensive when you compare them to unnecessary surgeries, so they can be helpful.

There are also certain medical procedures and services that have been overused in the past but can actually have a role as part of an overall pain management plan. Spinal cord stimulators and injections are among them, along with chiropractic care and spinal manipulation. These can help with function for certain patients, such as those with acute pain. But they must be integrated into an overall plan, and they are only appropriate for certain individuals.

Passive treatments, such as acupuncture and massage therapy, might be helpful for some pain patients, at least in the short term. But again, it needs to be used in conjunction with an active therapy program in which the patient is helping to manage his own pain through skills learned from CBT and other techniques.

One treatment on which both experts are hesitant to recommend at this point is medical marijuana, mostly because of its classification as a Schedule I drug under federal law. The science on it is just too sparse; there is no safety regimen around it and no protocols for when to use it, what type to use and how much could help.

“Prehab” is a relatively new term that might hold some promise. Think of rehab before the fact. It focuses on things like wellness, how to relax during the day and stress reduction techniques. The idea is to intervene with patients prior to surgery or other treatments and prevent poor outcomes. Patients who have fear avoidance or catastrophic thinking can be taught skills so they are better able to deal with their pain and stress later on.

Education programs are key in helping pain patients to avoid overuse of medications and services. Because so many do not understand pain or how to control it, they may seek multiple treatments to eliminate the pain.

Opioid Guidelines

The 2017 revisions to the ACOEM Chronic Pain Guidelines, released in May 2017, included an extensive section on behavioral health, the role of psychology and recommendations to integrate psychological principles in chronic pain.

The CDC’s guidelines for managing opioids have been invaluable in the attention they have brought to the opioid issue since they were released last year. However there has been some confusion and pushback, especially on the recommendations that deal with the morphine equivalent dose. The CDC recommends providers avoid or carefully justify prescriptions of more than 90 MED. Some payers have incorrectly interpreted that to mean physicians cannot prescribe above the 90 MED.

Another controversial recommendation says providers should only prescribe opioids for the duration of expected pain, typically between three and seven days. But some providers have been mistakenly told they can only prescribe the drugs for a specific number of days.

See also: Misconception That Leads to Opioids  

The Future

Both experts say a shift from fee-for-service to outcomes-based care could be a huge benefit because it would allow for a more holistic approach, including the integration of behavioral health. Putting behavioral health efforts on the front end of the claim is one of the biggest changes that they believe would help chronic pain patients. This would be a game changer in the workers’ compensation system and would cost more up front, but the speakers believe it would pay off in dividends.

Precision medicine is an emerging field that the speakers say could provide great promise for treating injured workers with chronic pain. It involves deep phenotyping patients on the front end and at each point of care. It includes an array of psychosocial variables and assessments to determine the specific needs of each patient for targeted interventions. It moves beyond the one-size-fits-all approach.

Technological advancements will allow for more and better treatment, such as apps and videos that reinforce behavioral health techniques. Telemedicine is a way to help keep patients engaged. Telehealth can allow for virtual face-to-face meetings between patients and psychologists. Virtual reality also holds promise as a way to help decrease pain levels during treatments.

Clearly there is much that the industry can do to reap better outcomes for our injured workers and, in turn, their employers. However, we need new ways of thinking; a change in the way we have been doing things. All stakeholders need to truly understand pain and what we can do to address it better and faster.

Dangerous Confusion on ‘Painandsuffering’

What is pain? According to Merriam-Webster, it is “the physical feeling caused by disease, injury or something that hurts the body.” Which is different than suffering: “to become worse because of being badly affected by something.” Often, these words are treated as synonyms (or as a single word, “painandsuffering”) when they are actually quite different. Pain is what happens to you. Suffering is how you handle it.

The confusion of these two terms can create issues.

The American Pain Society in 1996 described “pain as the fifth vital sign” (giving it equal status with blood pressure, heart rate, respiratory rate and temperature). The phrase created a perfect storm because it coincided with the message being delivered to medical schools and the healthcare industry that doctors had an opioid phobia and were under-treating pain. That was followed in 2000 by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) establishing standards for pain assessment and management. Then the Veterans Health Administration incorporated the new emphasis into its national pain management strategy. So, regardless of where a patient was treated and by whom, the (subjective, patient-driven) assessment of pain was one of the first questions asked and often drove treatment plans.

Then the new approach began to be questioned. A 2006 study by the VA found quantifying pain “did not increase the quality of pain management.” In June 2016, the American Medical Association recommended removing “pain as the fifth vital sign” and connected the idea to the beginning of over-prescribing of opioids. Opponents of the change say it will “make it even more difficult for pain sufferers to have their pain properly diagnosed and treated.” Proponents of the change say “pain is not a vital sign, but more of a symptom, and cannot be measured.”

So far, pain is still the fifth vital sign.

See also: Health Startups Go After 3 Pain Points  

The biggest problem is unrealistic expectations – patients often are told or come to believe they will be pain-free. When they’re not, and their condition becomes chronic, it sows doubt in the mind of both the patient and clinician.

The second biggest problem is that often the circumstances beyond their physical pain is ignored. I am convinced that dealing with what happens between the ears and at home is as important as what is physically wrong with the body (i.e. the biopsychosocial model).

So how is “pain as the fifth vital sign” measured? Sometimes it’s a scale of frowny face to smiley face. But often it’s a comparative pain scale, from 0 to 10. The Health Organization for Pudendal Education (HOPE) offers the best description:

  • 0 – No pain – Feeling perfectly normal.
  • 1 – Very mild – Barely noticeable pain, like a mosquito bite or a poison ivy itch. Most of the time, you never think about the pain.
  • 2 – Discomforting – Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails. Note that people react differently to this self-test.
  • 3 – Tolerable – Very noticeable pain, like an accidental cut, a blow to the nose causing a bloody nose or a doctor giving you an injection. The pain is not so strong that you cannot get used to it. Eventually, most of the time you don’t notice the pain. You have adapted to it.
  • 4 – Distressing – Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe really hard. So strong you notice the pain all the time and cannot completely adapt. This pain level can be simulated by pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails and squeezing hard. Note how the simulated pain is initially piercing but becomes dull after that.
  • 5 – Very distressing – Strong, deep, piercing pain, such as a sprained ankle when you stand on it wrong, or mild back pain. Not only do you notice the pain all the time, you are now so preoccupied with managing it that your normal lifestyle is curtailed. Temporary personality disorders are frequent.
  • 6 – Intense – Piercing pain so strong it seems to partially dominate your senses, causing you to think somewhat unclearly. At this point, you begin to have trouble holding a job or maintaining normal social relationships. Comparable to a bad non-migraine headache combined with several bee stings, or a bad back pain.
  • 7 – Very intense – Same as 6 except the pain completely dominates your senses, causing you to think unclearly about half the time. At this point, you are effectively disabled and frequently cannot live alone. Comparable to an average migraine headache.
  • 8 – Utterly horrible – Pain so intense you can no longer think clearly at all, and have often undergone severe personality change if the pain has been present for a long time. Suicide is frequently contemplated and sometimes tried. Comparable to childbirth or a really bad migraine headache.
  • 9 – Excruciating, unbearable – Pain so intense you cannot tolerate it and demand pain killers or surgery, no matter what the side effects or risk. If this doesn’t work, suicide is frequent because there is no more joy in life whatsoever. Comparable to throat cancer.
  • 10 – Unimaginable, unspeakable – Pain so intense you will go unconscious shortly. Most people have never experienced this level of pain. Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss have experienced level 10.

How many times have people said their pain is a 9 or 10 (or a 47) when they’re conscious, sitting upright and drove themselves to the doctor’s office? I have seen that manifold times in hundreds of chronic pain workers’ comp claims since 2003. But it’s easy to succumb to that kind of self-assessment …

I had the flu in February and went to a CVS Minute Clinic. One of the initial questions the nurse practitioner asked me (having been prompted to do so by her practice management software) was my level of pain. I truly felt miserable — body aches, high temperature, sneezing. For a brief moment, because I wanted to ensure a prescription of Tamiflu, I wanted to catastrophize (“an irrational thought a lot of us have in believing that something is far worse than it actually is“) and say I was a 9 or 10. But then I remembered all the times I had argued against that approach. And I remembered exactly what a 9 or 10 meant. So I resisted the urge and gave myself a 5 rating. I still got the Tamiflu that started the journey to recovery.

See also: Better Outcomes for Chronic Pain  

Pain is complicated and individual, so there is not a single answer for quantifying and treating it appropriately. However, I have three high-level suggestions:

  • Re-calibrate the scale. The clinician should educate patients on the true meaning of 0 through 10 and help them decide on a lower number that better describes their pain. That would require an actual dialogue between the clinician and patient. I understand that pain is unique and personal. But if patients can convince themselves their pain is a 6 instead of a 10 (or a 47), then managing it seems much more achievable.
  • Be honest. If there is going to be residual, chronic pain, the patient should know it. And own it.
  • Manage the pain. In my opinion, “pain management” is a term that is often misused. You can’t manage your pain if you’re comatose (i.e. sedated on opioids, benzos, muscle relaxants, et al.). Yet we often see “pain management” as a series of pills or injections that are passive and repetitive (in some cases, I think pain management clinics have become “addicted” to the repeat office visits). At some point, patients need to manage their pain rather than allowing the pain to manage them, and be taught how to do that. That could mean yoga, an active lifestyle, better nutrition, biofeedback, proper sleep hygiene, deep breathing exercises, mindfulness, volunteer work or any number of other methods in combination or isolation that work for the patient. The key is an internal locus of control (“he or she can influence events and their outcomes“).

I’m not saying pain isn’t real. For those dealing with chronic pain, it is very real. But I’ve chatted with and observed too many people with significant chronic pain who overcome it on a daily basis to live productive and happy lives. I know that chronic pain does not have to win. Instead, we need to re-define pain, re-define suffering and help people take back control of their lives.

I will finish with this wisdom from Dr. Stephen Grinstead:

  • Thoughts cause feelings
  • Thoughts + feelings = urges
  • Urges + decisions (choices) = actions
  • Actions cause reactions
  • Reactions could help or hurt management of pain

In other words, how you think about pain influences how much power pain has over you. So think differently.