Patient-Centered Care for Chronic Pain

My Take on the Biopsychosocial Model of Patient-Centered Care | Pain Medicine | Oxford Academic – Jianguo Cheng, MD, PhD, FIPP – September 2018

I am privileged to participate in the US Department of Health and Human Services (HHS) Pain Management Inter-Agency Task Force (PMTF) and in the National Academy of Medicine (NAM) Action Collaborative on Countering the US Opioid Epidemic.

Promoting patient-centered care is what I believe to be the most important mission of our profession.

And patient-centered care should be the guiding principle of policy-making by federal and state agencies, health care payers, and professional organizations and societies.  

Only when the patient is placed in the center of care can pain professionals begin to identify specific needs and develop a treatment plan designed not only to reduce pain but also to restore function and quality of life.

“Specific” is the key word here, and this is exactly what “standardized” doses do NOT accomplish.

Although chronic pain and addiction are both devastating chronic diseases, there are clear distinctions between the two in terms of cause, mechanism, treatment, and prognosis.

Each patient presents with unique needs that can be identified only through a comprehensive assessment and development of a precise diagnosis and differential diagnosis.

Patients with chronic pain disorders are most appropriately cared for by providers trained in pain medicine collaborating with their primary care physicians, whereas those with drug addiction should be treated by clinicians with proper training in addiction.

For those with both addiction and chronic pain, collaboration and coordination between physicians and their respective teams are required to ensure appropriate and empathetic care to achieve the most optimal outcomes for patients.

Pain physicians are skilled in recognizing comorbidities and patterns of aberrant behavior that can lead to an addiction diagnosis, such as opioid use disorder (OUD).

Stigma and misconceptions about chronic pain and addiction in our society are major obstacles to patient-centered care.

Poorly informed critics struggle to differentiate clearly between chronic pain, drug tolerance, dependence, and addiction, many times contributing to a confused narrative around chronic pain and opioid use.

I suppose this would make Andrew “heroin-pill” Kolodny “poorly informed” because he routinely conflates addiction and pain relief.

Overcoming these obstacles through education and communication is critical to achieving success in the fight against the dual crises of poorly treated chronic pain and the ongoing opioid overdose epidemic.

What can we do about people who do not want to be educated? (Again A. Kolodny is a prime example of this refusal to see and react to new evidence.)

Patient-centered care requires easy access to treatment options with demonstrated benefits by an evidence-based medicine approach balanced with the pain specialist’s knowledge of an individual’s own particular characteristics and experiences.

In patients with complex pain conditions, a multimodal approach to addressing the biopsychosocial nature of pain is often needed to achieve the best outcomes possible.

It is particularly important to value and utilize real-world evidence (RWE), which has been proposed by the Food and Drug Administration, supported by the research community, and validated by systematic reviews of health outcomes assessed with observational study designs compared with those assessed in randomized trials

Importantly, a clinician’s autonomy needs to be recognized and respected in the clinical decision-making process.

Another common misconception concerns the relationship between prescription opioids for patients with severe pain and illicit opioids–related morbidity and mortality among patients with addiction.

Poorly informed critics and policy advocates often make the assumption that opioid therapy for chronic pain is mainly responsible for drug-related deaths.

In fact, the death of patients due to treatment of chronic pain with prescription opioids has not been identified as a major contributor to the opioid overdose epidemic.

Indeed, there was a 22% decrease in the prescribing of opioids between 2013 and 2017, but the opioid-related deaths have continued to increase sharply among patients with drug addiction involving illicitly manufactured drugs (i.e., heroin, fentanyl) and often including multiple substances.

However, there are instances when prescribing opioids may be the most logical and effective treatment.

Opioid medicines can play a vital role when treating those suffering from extreme pain, who have tried and failed other treatments, to improve their quality of life.

But the decision to prescribe opioids requires a well-planned, closely monitored, and highly individualized approach by the treating physicians and their teams.

An opioid is rarely the first treatment option for chronic pain, but it can be an effective alternative after careful consideration of the patient’s needs, history, and other available treatment options

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