The “Decade of Pain Control and Research": Part II

Part II: What Are The Greatest Challenges Ahead?

In the year 2000, the Joint Commission on Accreditation of Healthcare Organizations released new standards for the assessment and management of pain in the facilities they accredit and certify. C. Richard Chapman, Ph.D., then the President of the American Pain Society, described this as “a giant step…a major leap forward”. A few months later Congress passed and the President signed a law that declared the ten-years beginning January 1, 2001 as the Decade of Pain Control and Research.

Charles E. Argoff, MD:

Charles E. Argoff, MD, is Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in New York. Dr. Argoff received his medical degree from Northwestern University’s Feinberg School of Medicine in Chicago, Illinois. He completed an internship in the Department of Medicine and a residency in the Department of Neurology at the State University of New York in Stony Brook and a fellowship in Developmental and Metabolic Neurology at the National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH/NINDS). (continued below)

"What is your personal evaluation of the greatest challenges ahead, as we enter the next decade?"

We now know that in the past, we were advocating for better recognition of the need to adequately treat chronic pain. We probably underappreciated the complexity of its treatment and unexpected problems like side effects and aberrant drug-related behaviors, most notably, diversion of prescription pain medications. Also, currently, there are changes happening in the regulatory environment, but we don’t know the extent of them, and what their ultimate effect will be. The worst-case possibility is that regulatory changes will have a chilling effect on chronic pain management going forward into the next decade; specifically on the use of opioids for the treatment of chronic pain. It is likely that fewer clinicians will prescribe them if the steps they will need to take are too cumbersome. This will likely decrease patient access to medications that may be an appropriate component of their treatment plan. On the other hand, there is the possibility that having increased rules will give structure to primary care clinicians, and “liberate” them to prescribe in the way they believe is best for the patient.

As we move forward into the next decade, we need to teach all providers that chronic pain like all other chronic illnesses can be challenging because of lack of treatment adherence. We know that misuse of medication is a risk but we should have the knowledge and tools to help us make good decisions, so clinicians will feel educated and comfortable as they proceed. Clinicians have to learn that treatment of chronic pain, like treatment of diabetes, requires a rational, logical approach.

Economics and healthcare is another very important issue as we move forward. Many programs that offered a multidisciplinary treatment approach to chronic pain, that in the long run would potentially decrease use of medication alone, have closed because of poor reimbursement. At both the academic medical centers and in the community clinics, one can reasonably say that ultimately “money rules”. While the question is asked “what can you do to increase revenue to the health care system”, no one is studying how much more effective an integrated approach to chronic pain treatment is, in order to give payers the incentive to support this kind of treatment. We need to combine a scientific approach and clinical practice, in order to measure outcomes and develop best practices. Guidelines by themselves won’t do the job.

I think the future is now, and that this is a critical point in time in pain management. We cannot make treatment more individualized if we are going down the road of limiting choices. We may not only be facing having the rug pulled out from under us from prescribing opioids, but off-label prescribing, which is often a very important aspect of treatment planning may go away as well. Payers are sometimes quick to label what I would consider the “art of medicine” as experimental. In the future, economic forces will likely play an even larger role in how health care providers can use the art of medicine.

I hope that enough clinicians will get together to use evidence-based medicine practices effectively recognizing as well that there is insufficient evidence to make all treatment decisions and that studies used to create evidence based guidelines do not reflect the average patient in most practices. We truly need to reorient the discussion as the patients being studied in clinical trials are not usually representative of the average chronic pain patient in the doctor’s office. We need to do a much better job of focusing on the types of patients that primary care providers see in their offices every day to make a real difference.

Dr. Argoff is a member of the International Association for the Study of Pain, the American Academy of Pain Medicine, and the American Academy of Neurology, among other professional organizations. He serves on the editorial board of the Clinical Journal of Pain and as a reviewer for the Journal of Pain, Brain, JAMA, Archives of Physical Medicine and Rehabilitation, Journal of Musculoskeletal Pain, Journal of Pain and Symptom Management, and the Clinical Journal of Pain. He is Co-Editor of the Neuropathic Pain Section of Pain Medicine.

Dr. Argoff has served as a guest editor for and published articles in the Clinical Journal of Pain and Current Pain and Headache Reports, among other peer-reviewed journals. He has written on many types of pain, including myofascial pain, spinal and radicular pain, and neuropathic pain. He has written on such treatments as topical analgesics, interventional pain management, botulinum toxins, and oral analgesics, and has contributed many book chapters as well. Dr. Argoff had an active role in the development of the diabetic peripheral neuropathic pain guidelines published in Mayo Clinic Proceedings, and he has contributed to other published neuropathic pain treatment guidelines. He is one of the editors of the recently published textbook Raj’s Practical Management of Pain, Fourth Edition. He is the co-author of Defeat Chronic Pain Now, a just published book for people with chronic pain. He has recently published the third edition of Pain Management Secrets.

Click here to read Part I of this two-part Clinical Roundtable.