COMPREHESIVE PAIN CARE
Comprehensive Pain Care Overview
Pain is the most common and compelling reason for seeking medical attention.1,2 The prevalence of chronic pain problems in the general adult U.S. population is high; estimates have ranged from 11% to 47% in recent large surveys depending on the specific sample, with a documented association between pain and impairment in physical and psychological functioning and lost work productivity.3 Recent estimates for the US cost of pain care range from US$560 to US$635 billion annually.4 This exceeds the annual expenditures for the nation’s priority health conditions (heart disease, cancer and diabetes) combined.5 Low back and neck pain, osteoarthritis (OA) and headache are the most common pain conditions in the United States and are leading global causes of disability in 2015 in most countries.6
This prevalence of pain is set in the context of the ongoing prescription opioid epidemic that continues to claim 130 lives a day in the U.S, where nearly 80% of heroin users reported misusing prescription opioids prior to heroin.7 The probability of long-term opioid use increases after as little as five days of prescribed opioids as the initial treatment of pain.8 While not addictive, nonsteroidal anti-inflammatory medications (NSAIDs) commonly used for pain carry risks of adverse events including gastrointestinal (GI) symptoms like nausea, abdominal pain, stroke, heart attack, renal failure and GI complications including acute and chronic bleeding as well as delaying healing of injury.9,10 There are 16,500 deaths annually from NSAID-associated GI complications among rheumatoid arthritis (RA) and OA patients alone;11,12 and as of the year 2000, 25% of all reported adverse drug reactions were attributed to prescription NSAID use.13
In response to the risks of pharmacological treatments for both acute and chronic pain, and more specifically to the ongoing opioid crisis, nonpharmacologic pain approaches are recommended as a first line of care by the Centers for Disease Control and Prevention (CDC)14 and the U.S. Food and Drug Administration (FDA),15 the Army Surgeon General Pain Task Force,16 the American College of Physicians (ACP),17 and as part of comprehensive pain care3 by the U.S Agency for Health Care Research and Quality (AHRQ),18 National Institutes of Health (NIH),19 the National Academy of Medicine (NAM, formerly the Institute of Medicine IOM)10 and the Joint Commission (TJC).20,21
Evidence-based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper
On January 1, 2018, the Joint Commission’s revised pain standard included nonpharmacologic options for pain as a scorable element of performance. In support of the Joint Commission’s decision the Consortium’s Pain Task Force has published a White Paper to serve as a source for the evidence-base of nonpharmacologic pain strategies as part of comprehensive pain care’
Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon RL, Wayne PM, Zador V. Evidence-based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY). 2018;14(3):177-211.The White Paper is open access and may be downloaded by clicking on the button below.
EVIDENCE SUMMARIES FOR THE TREATMENT OF PAIN
Noninvasive, Nonpharmacological Treatment for Chronic Pain:
A Systematic Review
Comparative Effectiveness Review U.S. Agency for Healthcare Research and Quality (AHRQ)
The Consortium and other pain experts have provided comments as part of the AHRQ call for predissemination peer review of this document. The document is posted here as a resource to provide a comparative effectiveness review of the evidence on noninvasive, nonpharmacological treatments for common chronic pain conditions, focusing on whether improvements are seen for at least one month post-intervention. While this results in not including some studies, by doing so it focuses on more sustainable benefits of nonpharmacological approaches.
Key Messages of the Review:
- Interventions that improved function and/or pain for ≥1 month:
- Low back pain: Exercise, psychological therapy, spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation (MDR).
- Neck pain: Exercise, low-level laser, mind-body practices, massage, acupuncture.
Knee osteoarthritis: Exercise, cognitive behavioral therapy (CBT).
- Hip osteoarthritis: Exercise, manual therapies.
Fibromyalgia: Exercise, CBT, myofascial release massage, mindfulness practices, tai chi, qigong, acupuncture, MDR.
- Tension headache: Spinal manipulation.
- Some interventions did not improve function or pain.
- Serious harms were not observed with the interventions.
ARTICLES OF INTEREST
OTHER NEWS OF NOTE
On September 18, 2017, the National Association of Attorneys General (NAAG) wrote to the America's Health Insurance Plans (AHIP) call for coverage to be revised to support non-opioid approaches to pain management. In the letter below, signed by 37 Attorneys General, NAAG requested that AHIP "take proactive steps to encourage your members to review their payment and coverage policies and revise them, as necessary and appropriate, to encourage healthcare providers to prioritize non-opioid pain management options over opioid prescriptions for the treatment of chronic, non-cancer pain."