Tuesday, February 06, 2018 Making Transformation Possible: Panelists at APTA Event Explore Paths Toward Rethinking Pain Management Ending the opioid crisis—or even just making a dent in it—is going to require nothing less than transforming an entire culture's attitudes about pain and its management. But panelists at a recent APTA event believe there are models and concepts out there that provide hope for a future in which multidisciplinary nondrug approaches to pain replace an opioid prescription as the norm in health care. At its February 5 live event, "Beyond Opioids: Transforming Pain Management to Improve Health," APTA brought together 7 panelists with a range of perspectives, from a patient whose multiple surgeries were accompanied by opioid prescriptions, to a physical therapist (PT) who works in a program that educates and empowers patients to take more control of their pain, to a congressman who is fighting to raise public awareness of addiction as a disease. The entire conversation was broadcast live on Facebook, and a recorded version is available for viewing. Though each speaker brought something different to the table, a few common threads emerged when it came to what it will take to truly address the opioid epidemic, particularly as it relates to pain management. Panelists tended to emphasize the need for increased and more open communication, better identification of risk factors for opioid abuse, greater use of multidisciplinary approaches to pain management, and the need for more education delivered to patients, providers, employers, and entire communities. Panelist Joan Maxwell's story served as a touchpoint for the night, highlighting the patient experience and bringing 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—9 in all over fewer than 3 years. Along the way, Maxwell experienced a stroke. And at every juncture, she was prescribed opioids, with few conversations about what to expect in terms of pain and what other ways her pain might be managed. Luckily for Maxwell, who is now a patient and family advisor for John Muir Health and patient-member of Patient & Family Centered Care Partners Inc, she was able to avoid addiction. Her brother-in-law, however, was not as fortunate: over the course of what Maxwell described as "2 failed back surgeries," he became addicted to opioids. His wife administers his drugs and is careful to hide the medications from him. "He was just a regular person like all of us," Maxwell said, "but just 1 surgery, and he was addicted." Maxwell holds out hope that things can change for the better, beginning with more conversations between providers and patients about pain. Both Grant Baldwin, director of the division of unintentional injury prevention for the Centers for Disease Control and Prevention, and Rep Donald Norcross (D-NJ) echoed Maxwell's call for better communication, albeit in slightly different settings. Baldwin told the audience that more outreach is needed to spread the word about the CDC's guidelines for chronic pain management and its recommendations for nondrug approaches as a first-line treatment, while Norcross spoke about the need for better communication to lift the stigma around addiction and help communities and the federal government focus on a disease model. Norcross even offered advice about getting the message out. "Make an appointment when your congressman or congresswoman is in your district, and give the real story," Norcross said. "This is not some urban issue that happens in the dark of night. This can happen anywhere." As medical director of Swedish Pain Services and president of the American Academy of Pain Medicine, Steven Stanos, DO, brought firsthand knowledge of the latest approaches to pain management. Stanos outlined an intensive multidisiciplinary process at Swedish Pain Services that involves PTs, occupational therapists, pain medicine specialists, pain psychologists, and nurses in group and individual treatment settings. Although Stanos admitted that it's a system not available to everyone, and cost can be challenging for some patients, patients everywhere should be wary of treatment that relies on pain medications only. "I always think that [the presence of an opioid prescription] is a marker that [patients] didn't have comprehensive care," Stanos said. "A lot of [what needs to change] is about education and unlearning maladaptive ideas." Sarah Wenger, PT, DPT, is doing just that through a "Power Over Pain" program that emphasizes individualized approaches to management, with a focus on education and honest conversations with patients. Wenger is a board-certified clinical specialist in orthopaedic physical therapy and an associate clinical professor at Drexel University's College of Nursing and Health Professions. In many instances, Wenger explained, patients need to come to grips with the idea that they may always experience some degree of pain—"I don't think zero pain is particularly realistic for any of us," she added—but that they can be empowered when they understand how to manage pain in healthy ways. "The truth is, most people don't feel really great on opioids," Wenger said. Echoing previous panelists’ emphasis on communication were the final 2 speakers, Tiffany McCaslin and Bill Hanlon, PT, DPT, who also is a board-certified clinical specialist in orthopaedic physical therapy. McCaslin, a senior policy analyst for the National Business Group on Health, sees a need for employers to come to grips with the impact opioids and opioid-based pain treatment is having on employees and, in turn, on the overall operation of the business itself. The concept is at the heart of a new summit program being rolled out by her organization. "We're pressing on our members to take a look at this issue with eyes wide open" and to reduce the stigma around addiction, McCaslin said. As a PT working in addiction recovery at the St Joseph Institute in Port Matilda, Pennsylvania, Hanlon often finds himself helping patients who have suffered from a pain treatment system that relies too heavily on opioids. But that's not the entire patient population, he explained—many of the individuals he helps don't have underlying pain but experience it for the first time in the form of withdrawal symptoms. In either case, he said, communication and a multidisciplinary approach are key. "The way we approach addiction needs to be multidisciplinary, just as the approach to managing pain needs to be multidisciplinary," Hanlon said. "And as we get all the disciplines involved and understand the psychology of the person…we can help them more and more." But according to Hanlon, that multidisciplinary help must begin with helping a patient to understand what's possible—without an overreliance on opioids. "It's about communicating with people," Hanlon said. "It's talking with people and letting them experience the wellness."