Behind the Numbers: Keeping the Patient at the Center of Pain Management
The Centers for Disease Control and Prevention (CDC) reports that over 115 people die from opioid overdose every day in the United States. In 2016 alone, 11.5 million people misused prescription opioids.
According to a Washington Post/Kaiser Family Foundation survey:
- 34% of respondents who had taken opioids for at least 2 months said they had become addicted or chemically dependent.
- 68% said the pain relief provided by opioids outweighs the risk of addiction.
- 31% said they had not tried managing pain with "treatments such as physical therapy, acupuncture, or meditation."
- 54% of opioid users' household members said they thought the opioid user would struggle to discontinue use.
Behind all these statistics are real people, with real stories, who simply want relief from pain. For some patients, properly dosed opioids can be beneficial. Some of these individuals may get relief from opioids, and some may not. Some may be at higher risk for addiction, and some may not. And many may not be aware of nonopioid therapies to help them manage pain with a better quality of life.
At APTA's recent "Beyond Opioids" panel discussion, guests highlighted several strategies for patient-centered care with regard to opioid prescription and pain management.
1. Clearly communicate the risks of and alternatives to opioids.
Patient advocate Joan Maxwell's story highlighted the patient experience and brought current weaknesses in pain management into sharp relief. Maxwell's journey as a patient began with a double mastectomy, which led to a staph infection and subsequent surgeries. Maxwell described her own experience with opioids:
Nine times I had surgery and 9 times I was prescribed opioids, and 9 times I never had a discussion with a doctor in advance about what my pain experience might be and what my options might be. There's a wonderful opportunity for communication and for patients to be educated in advance about pain and about their choices, and not just given a prescription for opioids.
Maxwell's story is not unique. In the Washington Post/Kaiser Family Foundation survey, only 65% of respondents said their doctor talked with them about the possibility of addiction when prescribing the drugs, and only 62% received education from their physician about other ways to manage pain.
The Centers for Disease Control and Prevention (CDC) guidelines for opioid prescription emphasize working with the patient to establish treatment goals before initiating therapeutic interventions.
2. Combine interdisciplinary therapies to improve pain, function, and quality of life.
Grant Baldwin, PhD, MPH, director of the division of unintentional injury prevention for the CDC, noted, "Postsurgery it does make sense perhaps to have a short script of opioids, but that that does absolutely need to be done in combination with the range of therapies from exercise to acupuncture, massage, yoga, cognitive behavioral therapy—a full range of treatment options.…the goal should be to improve pain, function, and quality of life. That's really what we're aiming for, and I think the physical therapy community is well poised to deliver on that."
Steven Stanos, DO, is medical director, Swedish Pain Services, and medical director, occupational medicine services, Swedish Medical Center, where they provide interdisciplinary team-based care for patients with pain, including physical therapy, occupational therapy, pain psychology, and relaxation training. "Patients have such complex stories and complex needs, we're not going to be able to [relieve their pain] with just 1 pill or 1 type of pill," Stanos observed. "I think it's a mistake to think of this as just an opioid—I always think the opioid itself is a marker that they didn't have comprehensive care."
3. Give patients realistic expectations for pain and pain relief.
A goal of "zero pain" is not realistic for anyone, says Sarah Wenger, PT, DPT. Wenger is a board-certified clinical specialist in orthopaedic physical therapy and associate clinical professor at Drexel University's College of Nursing and Health Professions. Providers should encourage patients to focus on "small-step goals" of participating in activities of daily living—even if that includes some pain—instead of anticipating a completely pain-free life.
Convincing someone in pain to stop taking pain medicine "is counterintuitive," said Wenger. "You have to build trust…and credibility. Patients need to understand you're not just trying to shoo them out the door, that you're there, you're committed."
"Pain and opioid use are both very nuanced and complicated problems, and everybody has arrived at them in a different and personal way, and so I think the way that we approach it needs to be very nuanced and very personalized," Wenger explained. "What I'm going to say to one person is not necessarily what I'm going to say to another person."
4. Recognize that addiction is a disease, not a "moral failing."
Maxwell, who is a patient and family advisor for John Muir Health and patient-member of Patient & Family Centered Care Partners Inc, was able to avoid addiction, but her brother-in-law was not as fortunate: After 2 failed back surgeries, he became addicted to opioids. "It's a good example of what is happening, because he was just a regular person like all of us, and just 1 surgery and he was addicted," said Maxwell.
Congressman David Norcross (D-NJ) has seen the effects of the opioid crisis up close in his home state of New Jersey. Norcross is vice chair of the Bipartisan Task Force to Combat the Heroin Epidemic. "[Opioid addiction] is not a moral failing. It's a disease. And the more we understand this, the more we can address it—knowing that I might have come in with shoulder pain, I take a pill and it's going to impact me one way, and you it impacts differently. What the CDC has done in prescribing guidelines is a great first step. It's multifaceted. It's across all areas. We in Congress created incentives for pain management: if you address pain management you get a better score for reimbursement. ….coming together as a country…is the only way we're going to be able to defeat this."
What are your patient stories? How do you approach pain management with patients and other providers?
You can watch the full panel discussion at www.apta.org/BeyondOpioids/.