Health and Wellness

An Interwoven Problem: The Pain and Opioid Crises

An Interwoven Problem: The Pain and Opioid Crises

William Kirsh, DO, MPH

As a practicing physician, I’ve had the opportunity to notice changes in the way pain has been managed over the years. In spite of all the opioid prescriptions that have been written and the focused efforts to tackle the “opioid crisis,” I’ve noticed that there has been no overall change in the amount of perceived pain people are experiencing.

We’ve ripped off the bandage, but there is still a gaping wound.

According to a Harvard Health webcast, we are left with a persistent problem – a pain epidemic. While we’ve acknowledged the need to treat acute pain with limited to no opioid use, treatment of chronic pain – a clinically distinct entity – is limited by an individual’s insurance plan.

Current health delivery organizations are challenged to provide realistic integrated treatments that balance clinical interventions with increasing co-morbid diagnoses in patients living longer with chronic conditions. A recent Washington Post article confirms that our patients are susceptible to inappropriate use of opioids to impact acute pain, coupled with minimal covered options to control chronic pain by other medications or modalities.

With the advent of big data analytics, we have vast systems of knowledge and longitudinal data that we can use to identify and help ameliorate many of these issues. With this in mind, here are five suggestions for using data to help patients manage their pain.

1. Stay in Control by Developing Best Practices for Your Patients

According to the Journal of Managed Care and Specialty Pharmacy, “Higher rates of opioid prescribing over the past 2 to 3 decades may be attributed in part to historical changes in pain management guidelines, Joint Commission requirements for routine pain assessment, identifying pain as the ‘5th Vital Sign,’ pharmaceutical industry promotion, and changes in reimbursement and out-of-pocket payment for prescription opioids.”

Using a longitudinal database (anonymized information from many patients over many years) can help you identify all the patients on opioids in your patient population over time. In your own practice, you can pull out patients with specific pain diagnoses. Then, take a deeper look at the patient data. How is their pain being treated? How well-controlled is it? Are there other options to better manage their pain? Could off-label use of other classes of medications be just as effective?

Consider using new risk-scaling scores to document and better manage your patients with multiple co-morbidities, with tools like the Neuropathy Pain Scale by Bradley S. Galer, MD, or a risk aggregation tool such as the Opioid Risk Tool by Lynn Webster, MD. Some patients have chronic conditions that may necessitate long-term opioid therapy. By aggregating data longitudinally from the electronic medical record (EMR), you will be able to practice medicine on your terms. Your own EMR longitudinal database helps validate your clinical judgement. Through harvesting your data, you can meet the needs of those patients who need chronic opioid therapy monitoring and treatment.

2. Identify Patients at Risk of Abuse

Data can also be used to identify patients at risk for opioid abuse. As the Framingham study was key to identifying risk factors for developing cardiovascular disease, having the ability to evaluate patient data over time could help us create a risk stratification tool for those patients with certain social determinants of health, or medical conditions that may predispose one to an opioid problem. Living with chronic pain changes the brain over time – chemically AND physically – which leads to inherent problems with pain control due to an increased pain threshold.

In 2001, The Joint Commission first established standards for pain assessment and treatment, “in response to the national outcry about the widespread problem of under treatment of pain.” Although this was well intended, there was no clear way to risk stratify patients. We were encouraged to utilize interventions for pain without the knowledge of the full ramifications of what that would do.

While we have standardized pain scales, the scales say nothing about risk factors a patient may have for abuse or dependence, specific elements of past medical history or social determinants of health that may affect how they experience and tolerate pain. Not everyone’s pain is the same. It’s time to rethink the use of a pain scale without having a comparable risk stratification, reexamine how we capture pain scores, and use the longitudinal data we have to help categorize and risk stratify our patients.

3. Identify Patients at Financial Risk

Most patients with comorbid states have chronic pain. Unfortunately, they may also have minimal to no insurance coverage. This translates into few alternatives for pain management. If they cannot afford gym memberships, healthy food and safe housing, they will most likely not have an insurance plan that covers alternative modalities for treating chronic pain. In short, they can’t control their pain well, they don’t feel good and many times they end up in the hospital for extensive and expensive workups. Insurance coverage (or lack thereof), predicts behavior of your patients because it limits the scope of what the patient is going to do. If you prescribe a medication or therapy they cannot afford, your scope of practice is limited.

Until risk stratification of patients with chronic pain becomes part of a public policy to help change behavior, care and outcomes, the best way to help them is by using longitudinal data to identify those patients at risk to better manage the chronic conditions that may lead to costly hospitalizations. In a 2016 Pain News Network article, American Medical Association board chair Patrice Harris, MD, MA, said, “Insurers must cover non-opioid and non-pharmacologic therapies that have proved effective. Insurers must take a broader view to give patients and physicians more choices. These policies will save lives. That's the bottom line.”

4. Identify Patients with Comorbid States

In an article from the Journal of Managed Care and Specialty Pharmacy, researchers found, “The costliest patients diagnosed with opioid abuse had high rates of preexisting and concurrent chronic comorbidities and mental health conditions, suggesting potential indicators for targeted intervention and a need for greater awareness and screening of comorbid conditions.”

Some of the most common comorbidities included mental health problems, diabetic neuropathy, chronic musculoskeletal conditions and cancer. Longitudinal datasets allow us to hone in on these patients and begin to consider better tools for risk stratification for them. Even those patients coming in for an acute issue many times have an underlying chronic disease state. It’s vital to be diligent with each patient interaction as we seek to understand their comorbid states and individual risk factors.

The following charts from the Centers for Disease Control and Prevention and Kaiser Family Foundation illustrate the distribution of overdose deaths and main reasons for consumption of opioids among U.S. adults.

Statista: Distribution of opioid overdose deaths in the U.S. in 2016, by age

Statista: Share of main reasons for consumption of opioids among U.S. adults as of 2017

5. Find the Right Resources for Your Patients

By using longitudinal datasets, we’re able to identify patients’ chronic conditions, comorbid conditions and social determinants of health. Having this information empowers all of us as providers to direct our patients to the best solutions for them – a podiatrist for diabetic foot care, a psychologist for mental health concerns, an orthopedist for treating chronic back pain, or a social worker to help navigate the system to find better housing or sources for healthy meals. The February, 2018 American Journal of Public Health notes that, “Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval, its etiology closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness, “ and, “The social determinants lens lays bare the urgency of integrating clinical care with efforts to improve patients’ structural environment.” We must, as providers, challenge ourselves to seek out resources that empower our patients while considering their unique social determinants of health.

Considering Multiple Approaches

An American Pain Society monograph noted, “Pain is subjective, so no satisfactory objective measures of pain exist. Pain is also multidimensional, so the clinician must consider multiple aspects (sensory, affective, cognitive) of the pain experience … no single approach is appropriate for all patients or settings.”

It is my hope that as we focus on our patients and their longitudinal data, and utilize tools to classify their risks appropriately, we can begin to tackle the interwoven pain and opioid crises.

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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Updated May 15, 2019