Reducing the global burden of chronic pain

Reducing the global burden of chronic pain – Beth D. Darnall, Clinical Professor, Stanford University School of Medicine

The profound global burden of chronic pain is increasing as the world population ages, and particularly so for low and middle income countries.

Reducing the global burden of pain requires

  • national policy and investment to develop coordinated local, national and international efforts to improve professional and public pain education;
  • promotion of the biopsychosocial model of evidence-based pain care;

However, the biopsychosocial model is based on poor or biased evidence. Many pain patients ultimately respond only to the effectiveness of opioid therapy. 

  • technological infrastructure to collect better data and for treatment stratification and delivery; and

A huge problem has been the lack of data collection on patient outcomes from the cornucopia of policies being handed down from on high, which are created only by anti-opioid interests working to prevent addiction.

  • the integration of patient-centered principles into policies and systems to ensure ethical and individualized care, patient protections, and careful attention to aging and disadvantaged populations.

CHALLENGE

Undertreated pain contributes greatly to worldwide human suffering and economic  burden

Estimates for the Global Burden of Disease revealed that low back pain – the most common chronic pain condition worldwide – was the leading cause of years lived with disability in most countries and territories.

Health policies must ensure support for economically sustainable solutions that address the growing pain treatment needs of the world population.

Is chronic pain its own disease or a symptom of something else?

In short: pain can be either or both.

In May 2019 the World Health Organization (WHO) adopts the new version of the International Classification of the Diseases (ICD11) with expanded diagnostics for chronic pain.

Developed by a task force of the International Association for the Study of Pain (IASP), the new diagnostic categories distinguish between

  • chronic primary pain as being its own disease, and
  • chronic secondary pain as pain being the symptom of an underlying condition.

INVEST IN PAIN EDUCATION

Pain education is insufficient across all disciplines of healthcare.

Pain education is insufficient in public and consumer domains.

PROMOTE PAIN POLICIES THAT EMPHA­SIZE THE BIOPSYCHOSOCIAL TREAT­MENT MODEL TO REDUCE AND PREVENT CHRONIC PAIN

A biomedical treatment approach is reductive and less effective.

Pain is a psychosensory experience, and treatment response to a wide range of medical treatments may be optimized with comprehensive approaches that address the individual factors that impact pain.

Failure to address the individual psychosocial factors may

  • perpetuate a purely biomedical pain treatment model,
  • contribute to overmedicalization and treatment inefficiencies,
  • promote poor opioid prescribing practices seen in Western nations, and
  • poor health outcomes.

Prevention strategies are underutilized

Human suffering, as well as the persistence of pain, may be mitigated with early pain treatment. Policies should encourage early intervention and inclusion of behavioral medicine strategies.

LEVERAGE TECHNOLOGY AND BIG DATA TO PHENOTYPE, STRATIFY AND DELIVER TREATMENTS

Current data on pain are poor

Poor data contribute to

  • poor quality pain care,
  • perpetuate medical mistakes and financial inefficiencies, and
    [Mentioning financial inefficiencies between serious patient-impacting harms seems strange…]
  • compound human suffering.

Better data on pain is needed…

The reason we have no data on pain is because all the studies of pain use the measurement of opioid dose, not patient pain or other outcomes, as the focus of the studies.

…to inform the development of improved policy and practice guidelines, and to characterize not just population level needs, but also the needs of vulnerable “outliers” – patients with complex comorbidities, high-impact chronic pain, and unique care needs.

To me, it seems like almost all pain patients are “outliers” with their very individual development, types, and locations of pain, in addition to responding very differently to various palliative measures.

Leveraging big data requires technological transformation and catchment of digital data generated in health care in real time – whether clinical, delivery process, short and long term outcomes, or financial. Such data “…should be compiled and protected as resources for managing care, capturing results, improving processes, strengthening public health, and generating knowledge.

POLICIES MUST EMPHASIZE PATIENT-­CENTEREDNESS

Alarming trends in rigid policies expose patients to harms

Pain is an individual experience and response to treatment is variable.

Policies should be flexible and allow for individual, patient-centered treatment approaches.

Without such flexibility, the medical system may unwittingly inflict further stigma and suffering on patients by forcing inappropriate care.

For instance, in the U.S., some organizations have addressed the need to reduce misprescribing of opioids in some patients by creating rigid policies that limit access to opioids for all patients with chronic pain.

Such rigid policies have led to increased suffering for the most vulnerable patients living with a wide range of complex medical conditions and comorbidities, and spurred the publication of an international stakeholder letter expressing deep concerns for patient protections.

The worldwide group Human Rights Watch published a report citing these actions as violations of international human rights standards:

“…government[s] should seek to avoid harming chronic pain patients: some patients still have a legitimate need for these medications, while others who have been on these medications for many years but who may not be benefiting from them should be weaned off them safely and in accordance with best medical practice.

If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to minimize and measure the negative impacts of these policies.

Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with – and sometimes blamed for – the overdose crisis and characterized as ‘drug seekers,’ rather than people with serious health problems that require treatment”.

I’ve posted about this issue:

Patient inclusivity is poor

Local, national and international efforts should include patients as key stakeholders in pain research and policy development, and ensure that patients are empowered consumers, informed of their choices and their rights in care.

We patients are the ultimate stakeholders and the ones whose input is not only ignored but actively suspected as encouraging drug abuse.

Unfortunately, some of the online vitriol expressed by suffering pain patients is so hostile as to lead to such an impression.

Policies and healthcare delivery systems should encourage shared decision making models between healthcare professionals and patients, as well as encourage patient involvement in all aspects of their pain care.

In conclusion, chronic pain is a pressing and growing global problem, with older adults suffering disproportionately.

The aging of the world population suggests that current systems in all nations are ill equipped to address ever burgeoning pain care needs, and policies are needed to rapidly develop effective infrastructure.

Investing in the implementation of policies that support

  • collection of better data,
    [as opposed to the CDC which is collecting NO data on the effects of their guideline, despite calling for such data to be collected in the guideline itself]
  • systems efficiencies, and
  • improved access to pain treatment.
    [treatment that works, not woo-woo methods proposed by those without serious pain]

stands to reduce the years lived with disability, increase productivity, decrease economic burden and reduce human suffering.

Professional and public pain education are essential.

The current public “pain education” is that chronic pain is a mental issue of being weak (less resilient or mindful) or having a bad attitude (catastrophizing).

Policies should emphasize evidence-based treatments, and those that empower patients to engage as active participants in their chronic pain care.

The currently suggested alternatives to opioids are NOT evidence-based, even though they are actively promoted by government agencies, including the CDC and Oregon’s HERC.

Technology and learning health systems may be leveraged to better characterize, risk and treatment stratify, monitor patient response, and as novel and sustainable systems for rapid, on-demand treatment delivery.

Future international integration of learning health systems may expedite knowledge and transform pain care efficiencies globally.

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