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Formulary Frontlines: Challenges of Pain Management
Pan is the leading public health problem in the United States and the most common reason people seek medical care, representing a major clinical, social, and economic problem.1,2 A landmark report issued by the Institute of Medicine3 (IOM) in 2011 found that acute and chronic pain affects large numbers of Americans, with 100 million adults burdened by chronic pain—more than the total affected by heart disease, cancer, and diabetes combined. Pain also costs the nation $565 billion to $635 billion annually in direct medical treatment and lost productivity.3
Despite the prevalence and staggering economic pain burden in the United States, the IOM report3 stated that chronic pain is “underreported, underdiagnosed, and undertreated,” pointing to persistent deficiencies in access to evidence-based and co-ordinated models of care.
Challenges in Managed Care
Barriers to effective management of pain can lead to inadequate pain relief, can increase risk of dependence, and can add additional costs to the health care system. Chronic pain poses many challenges to patients and primary care providers (PCPs) including power struggles and a lack of mutual trust. For PCPs, stressors are often related to opioid prescribing, which is perceived as adding significant complexity to patient care, including concerns about inadvertently facilitating or contributing to addiction.4
The significant increase in opioid abuse and overdose deaths has intensified the concern about the appropriateness of opioid therapy for chronic pain management in primary care.4 According to the National Institute on Drug Abuse,5 the total number of opioid pain relievers in the United States has skyrocketed in the past 25 years. In 2013, physicians wrote 207 million opioid prescriptions.
A recent article in The Ambulatory M&A Advisor6 examined challenges physicians face in 2016 in pain management. Robert Twillman, executive director, American Academy of Pain Management, who was interviewed for the article, noted that one of the biggest challenges for pain management comes through “sharp increases in the amount of regulatory activity coming out of the state legislatures, other regulatory agencies within states, and even the federal government.” Another hurdle is reimbursement for management practices, especially if those practices want to do something more than write prescriptions or perform procedures. “Even those who are doing procedures are having more challenges getting them paid for, so it is a really challenging environment right now,” said Twillman.6
A study published in 2010 in the Journal of Managed Care7 identified lack of coordination of care as one of the biggest obstacles involved in treating opioid dependence. Physicians also face the challenges of managing comorbidities and dealing with relapse. Another challenge is the lack of professional education and training among health care professionals.8
Strategies for Improving Pain Care
The need for addressing pain burden in the United States is crucial. To that end, two government agencies8,9 have taken steps to provide guidance in properly treating and reducing the pain epidemic. The National Pain Strategy, the federal government’s first coordinated plan for improving pain care in the US, outlines recommendations for improving overall pain care in 6 key areas. The areas include population research, prevention and care, disparities, service delivery and payment, professional education and training, and public education and communication.8
To combat the increasing number of opioid overdoses in the United States, the Centers for Disease Control and Prevention (CDC) issued new recommendations for prescribing opioid pain killers outside of cancer treatment and palliative care.9 The 12 recommendations—aimed specifically at PCPs—intend to improve communication between clinicians and patients concerning the risks of opioid therapy and those associated with long-term opioid use.
In West Virginia, the state hit hardest by opioid overdoses, the CDC guidelines have been taken a step further. An “Expert Pain Management Panel,” composed of pain specialists, pharmacists, and health insurance representatives was created with the goal of taking on opioid prescription abuse in the state.10 The panel developed a new pain-prescribing algorithm, which has yet to be finalized, that provides medical personnel with a step-by-step guide for which treatment to prescribe to patients first, moving them through 4 categories of treatment from least potent to most. Timothy Deer, MD, co-chair of the panel, acknowledged getting payers on board may be a challenge but “hopes a state-approved algorithm will encourage insurers to approve pain treatments other than opioids more frequently.”10
To overcome the challenges in pain management, a collaborative approach among physicians, managed care organizations, payers, and other stakeholders is needed.
1. American Pain Society. What is the impact of untreated and undertreated pain? http://americanpainsociety.org/about-us/press-room/overview. Accessed April 21, 2016.
2. Phillips CJ. Economic burden of pain. Expert Rev Pharmacoecon Outcomes Res. 2006;6(5):591-601.
3. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.
4. Bergman AA, Matthias MS, Coffing JM, Krebs EE. Contrasting tensions between patients and PCPs in chronic pain management: a qualitative study. Pain Med. 2013;14(11):1689-1697.
5. National Institute on Drug Abuse. America’s addiction to opioids: heroin and prescription drug abuse. https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed April 21, 2016.
6. Romero R. 2016 pain management challenges. The Ambulatory M&A Advisor. February 8, 2016. http://www.ambulatoryadvisor.com/pain-management-challenges/. Accessed April 21, 2016.
7. Jan SA. Patient perspective, complexities, and challenges in managed care. J Manag Care Pharm. 2010;16(1 suppl B):S22-S25.
8. US Department of Health and Human Services. National Pain Strategy. March 2016. http://iprcc.nih.gov/docs/drafthhsnationalpainstrategy.pdf. Accessed April 21, 2016.
9. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49.
10. Jacobs H. The state hardest hit by the opioid crisis thinks it has a solution. Business Insider. April 20, 2016. http://www.businessinsider.com/west-virginias-solution-to-the-opioid-crisis-2016-4. Accessed April 21, 2016.
