Move Beyond Drugs to Manage Pain

Editor’s Note: This piece originally appeared in US News

This summer, the normally deadlocked Congress overwhelmingly passed the Comprehensive Addiction and Recovery Act to attack the opioid dependency that is ravaging the country. If funding is forthcoming and the law takes full effect, most attention will be on provisions designed to reduce opioid prescribing and help patients get treatment for addiction. An equally vital element addresses what to do about the millions of Americans who will continue to suffer from chronic pain as their opioids are withdrawn.

The legislation establishes an interagency task force headed by the secretary of Health and Human Services to review and modify best practices for pain management. For the past 15 years, the standard practice has been opioid prescriptions, which work quickly and cheaply for acute pain but have had a perverse effect on how we manage chronic pain.

With chronic opioid therapy, physicians are encouraged to employ so-called safe use policies – urine testing and signed patient contracts to use the medication as directed. Typically, patients taking opioids under these conditions have opioids in their bloodstream at all times, which makes it more likely that the drug will be taken in larger amounts or over a longer period than was originally intended. Safe use in primary care, coupled with social pressure by specialty physicians to treat pain aggressively for moral reasons, led to a vast rise in prescribing across the U.S. over the last decade and a half, enough to keep every American on opioids around the clock for a month.

The task force needs to look back prior to the epidemic when the first-line treatment for chronic pain was not drugs. Teams of occupational and physical therapists, social workers, physicians and psychologists – frequently operating in multidisciplinary centers – addressed the social, psychological, economic and physical components of pain. The treatments rolled out over several months and were tailored to each patient’s needs. They involved a wide range of therapies including exercise, biofeedback and stress reduction. They worked. They made patients physically stronger and gave them the self-management skills that helped them lead more fulfilling and productive lives.

Unfortunately, the treatments were expensive, especially compared to 15-minute office visits and a bottle of pills. By the late 1990s, insurers stopped paying for multidisciplinary pain care and most centers did not survive. Today, integrative care is not easily coordinated or reimbursed.

That earlier era of chronic pain management can be revived with less expensive avenues of access, better incentives and improved reimbursement. We recently completed the largest clinical trial of pain coping skills ever conducted, using nurse practitioners embedded in community medical practices. Historically, patients could only learn these skills in mental health settings from the few clinical psychologists trained in pain management. The nurse practitioners, working on salary in primary care and specialty clinics, achieved comparable outcomes in reducing pain, fatigue, emotional distress and use of medication. This success led us to develop a 2.5-day workshop to train nurse practitioners and other health providers to deliver pain coping skills that help patients stay off opioids.

With private insurance claims for opioid use disorder having increased 3,203 percent since 2007, paying a nurse practitioner for 10 weekly 45-minute sessions makes economic sense as an alternative, especially if the care generates long-run favorable outcomes that reduce costs for insurers and providers.

Medicare can lead the way in making pain coping skills widely available. Most important, it needs to create billing codes that make the services reimbursable. Second, it could set quality performance standards that would promote integrative solutions. Providers that meet or exceed the standards would receive a portion of the savings they generate by keeping patients off addictive medication.

In addition, physicians need help in understanding what is available for their patients beyond drugs. The Centers for Disease Control and Prevention issued some helpful guidelines in March, and policymakers need to consider standing orders for physical, occupational and psychosocial pain management that would reduce pain and improve patient function.

That kind of pain management is saving Heather Brumby of Huntington, New York. Brumby, 28, who suffers from fibromyalgia, had been prescribed 200 tablets of Percocet a month. “I had to get off them,” she says. “I can see how people can become addicts. They only numbed me, and then the pain came back worse.”

With nurse practitioner Christine Stamatos guiding her, she now undergoes hold-and-release treatments on her right hip and massage on her upper thigh, among other therapies. “I could feel the release of pressure,” she says. She has learned techniques for relaxation and coping at home. Now when she senses a wave of pain, “I’m a co-pilot in managing it.”

The days of suffering pain at level 10 on a scale of 1 to 10 are over. “I’m on a path,” she says. “I’m starting to see the light.”