Opioids and Pain
Why do people experience pain?
Acute pain is an unpleasant yet normal and necessary experience. As part of an evolutionary process, pain can act as a warning sign in response to a harmful stimulus. The unpleasant quality of the sensation prompts individuals to act in a way that limits damage or heals the pain, whether that be withdrawing a hand from a hot stove-top or seeking medical treatment for a broken bone. At its core, pain protects people from incurring damage from adverse internal or external factors. Without pain, people would not be aware of damage that has occurred to their body and be able to appropriately respond. Although pain is a necessary part of the human experience, its persistence can result in a decreased quality of life.
Pain is often a symptom rather than a diagnosable condition. Its classification is complex and different types occur through unique mechanisms in the body. Acute pain is sudden in onset and is a time limited physiological response to tissue damage caused by a variety of conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain from surgery or other procedures. Chronic pain often begins as acute pain; however, it is persistent and recurrent, lasting longer than three months. The long held belief is that in some persistent cases, pain can cause neurological changes in the body that lead to pain even without bodily damage. However, new research is challenging this view by identifying improper coordination and combination of care and unaddressed underlying conditions as the cause for persistent pain.
Pain’s pathway in the body is complex and involves many bodily systems. Nociceptive pain arises from tissue damage and acts by sending a message from the tissue through the nervous system to the brain. This type of pain is impacted by the body’s movement, position, and load. Examples include musculoskeletal injuries such as strains and breaks, or injuries to the skin such as burns and stings. Neuropathic pain arises from damage directly to the nervous system and often presents itself through burning or stabbing sensations. An example of this pain that most people have experienced is hitting a “funny bone,” however other experiences result from instances of disease such as multiple sclerosis or opioid addiction, or medical treatments such as chemotherapy. These two types of pain can, and often do overlap. Separate from neuropathic pain, is hyperalgesia – pain related to nervous system dysfunction. When experiencing this type pain, an individual’s nervous system is communicating signals of pain to the brain in a way that is not consistent with the actual danger of the stimulus. This results in significantly increased severity of pain.
How should pain be treated?
The way each person experiences pain is dependent on an intricate network of biological, psychological, and social factors. This network determines pain severity, how it evolves, and what treatment pathway will be effective. An initial evaluation that considers medical and biopsychosocial factors related to a patient’s pain is an important component to ensuring comprehensive care. Determined by this evaluation, an individualized, multidisciplinary, and multi-modal approach is most effective for managing pain.
Fundamentally, chronic pain is a chronic injury, and focusing on the origins of pain is the first step to relieving it. A multidisciplinary approach facilitates that process by addressing the different personal aspects that contribute to painful conditions, including biological, psychological, and social factors. A multi-modal approach involves the synergy of different clinical disciplines in a pain treatment plan, including medication, restorative therapies, interventional procedures, behavioral health approaches, and complementary or integrative health. An individualized approach involves the person experiencing pain being treated in the way that best fits their definition of success and functional improvement.
To accomplish this, integrated care is necessary. Integrated care involves primary, mental health, and substance abuse care being systemically coordinated. Traditional healthcare is often siloed and relies on specialists to treat different aspects of patient’s health; however encouraging a team-based approach to a patient’s treatment plan can optimize patient outcomes and experience. The complexity of pain treatment not only requires the presence and coordination of a number of providers on this team, but also the right sequence and combination of the care that they provide. Patient navigators can be particularly valuable in coordinating appropriate care. There is evidence to support that an integrated approach reduces the severity of pain and improves function and overall quality of life.
The Biopsychosocial Model
Several biological factors can influence how any one individual experiences pain; including age, genetics, hormones, weight, and diagnoses of the condition causing pain.
Psychological factors such as mood, stress, trauma, and coping skills can all impede or facilitate pain. Conversely, experiencing pain can also have a significant impact on one’s psychological state.
Social determinants of health have a role in the progression of pain-related conditions. These include the economic and social factors that influence differences in health among certain groups.
Multiple classes of medication can be used for managing pain with the goal of ensuring patients have access to the most appropriate treatment to minimize their adverse outcomes while enabling a better quality of life. These medications can include opioid and non-opioid options.
Behavioral Health Approaches
Treatment outcomes can be significantly improved by addressing psychological, cognitive, emotional, behavioral, and social aspects of pain. Examples include cognitive behavioral therapies and mindfulness-based stress reduction.
Restorative therapies are focused on movement modalities, including those administered by physical therapy and occupational therapy professionals. Examples include traction, bracing, ultrasound, and therapeutic exercise.
Complementary and Integrative Health
Complementary and integrative approaches to health involve practices such as acupuncture, tai chi, yoga, and massage. These are typically successful when integrated with the other listed modalities.
Available as both diagnostic and therapeutic modalities for pain, interventional approaches are minimally invasive interventions that alleviate pain and minimize oral medications. Varying in intensity, these procedures can include joint injections, steroid injections, stem cell therapy, and more.
Why isn’t pain being treated appropriately?
People experience many barriers in treating their pain. The number of a Americans living with pain is far outpacing the number of physicians who are certified pain specialists. Because of this shortage, an increased responsibility is put on primary care providers to address pain despite inadequate time and resources.
Additionally, insurance coverage and provider reimbursement for integrated, multimodal pain management services is often insufficient. Clinical direction for payer guidelines is often outdated and inconsistent, impeding the delivery of adequate, timely, and affordable treatment while negatively impacting patients financially and psychologically. Although an individualized, multidisciplinary, and multimodal approach is most effective for managing chronic pain, current payment models do not support this approach.
At a cultural level, there are misunderstandings about what it means to experience pain. Taking a biopsychosocial approach to treating pain often takes significant time and effort on behalf of patients and providers. However, past and present healthcare ecosystems have often perpetuated a more passive, or “quick-fix” approach to pain treatment. This approach does not consider whether the underlying condition causing pain has been resolved or whether the patient’s desired functional status has returned, but rather only if the symptom of pain has increased or decreased.