More than one in 10 American adults experienced pain every day for the past three months, according to data from the National Institutes of Health. When pain lasts three months or longer, it is considered chronic pain.
The prevalence of chronic pain in the U.S. lies at the root of an ongoing epidemic of prescription opioid abuse. Since 1999, according to the Centers for Disease Control and Prevention (CDC), the amount of opioids prescribed in the U.S. has nearly quadrupled.
In 2016, there were enough opioids prescribed to fill a bottle for every adult in the U.S.
Measuring our progress
Our nation’s staggering opioid use numbers got the attention of Baylor Scott & White Health clinical leaders, headed by Robert Probe, MD, chief medical officer for Baylor Scott & White. In a project co-led by Michael Reis, MD, chief medical officer for the central regional clinics, and Judy Embry, Ph.D., pain psychologist and endowed chair in family medicine, electronic health records were used to look at the prescribing patterns of the system’s family and internal medicine doctors and advanced practice professionals. The focus was on the number of patients who were prescribed at least a 30-day supply of opioids during a three-month period.
They found there was a wide range of prescribing levels, from one or two patients to 120 or more patients. Half of the medical providers prescribed opioids to fewer than 10 patients.
“As doctors, we like to know where we are in our peer group. Doctors want to do the right thing,” Dr. Reis stated.
The results were shared with these medical professionals, along with education on the latest research and recommendations regarding treatment of chronic pain and use of opioids.
The efforts are paying off. Dr. Reis said there has been a clear decrease in opioid prescribing, based on analysis of electronic health records and anecdotes shared by physicians. He also reported these are just the first steps Baylor Scott & White is taking to help our physicians protect patients with chronic pain, while continuing to provide appropriate and effective treatment.
Changing how we view chronic pain
For decades, conventional medical wisdom was that patients with chronic pain would benefit from daily doses of opioids. It is now clear that the risks and side effects of chronic opioid use are significant, and the benefits are often modest or absent. That understanding is now being reflected in changes to how we treat patients with chronic pain.
For new patients experiencing chronic pain, we’re focusing on the beginning of the timeline — taking precautions to protect patients from the potential negative side of opioids, instead of waiting for it to happen before we intervene.
“The focus has been on the end of the timeline (of addiction), after there is already a problem,” Dr. Reis said. “People get used to them and don’t want to do without them. We want to shift the focus to the beginning of the timeline and control how we prescribe. The goal is to educate earlier in the pathway. We focus on the dangers of more than a few days (of opioids) to prevent new cases of opioid dependence and addiction.”
There are extra safety measures in place to help physicians do just that. Patients who are prescribed opioids for chronic pain must sign an agreement pledging that they will not share or sell these meds, and that they will get their opioid prescriptions from only one doctor. They are screened to ensure they are taking the prescription rather than “sharing” the drugs with others. There is also a state website where doctors check to verify the patient is not already getting an opioid prescription elsewhere.
Helping patients “get their lives back”
For many patients with chronic pain, it’s hard to live an active lifestyle and be involved in normal daily activities.
“With pain, there is a mind-body connection,” said Timothy Clark, Ph.D., a neuropsychologist at the Baylor Center for Pain Management in Dallas. “If you decrease emotional stress, you suffer less pain. Pain defocuses you over time, often leading to erosion of lifestyle and not working. People with chronic pain syndrome don’t schedule things.”
Now, the goals of chronic pain treatment are to enhance the patient’s involvement in daily activities and to improve their quality of life. Rather than simply measuring the patient’s perception of pain, which is often not an accurate gauge, medical providers are urged to monitor function and activity level as indicators of patient improvement.
“Chronic pain is overrepresented in the brain,” Dr. Clark said. “The typical reaction to pain is rest and medication. The old solution is the new problem. We need to get people activated.”
The problem we now face is the “legacy patients,” those who have been on high-dose daily opioids for years. Many primary care practitioners care for these patients, though they may or may not have initiated the opioid treatment regimen.
“Opioids are very effective for acute pain for three to seven days,” Dr. Reis said. “You shouldn’t be afraid to take them for a short period. But you need to resist the desire to take them longer than that because you risk becoming dependent or even addicted to them. You’ll find the pain level gets worse unless you increase the dose. But when you need more and more medicine, your functioning gets worse, and eventually the pain does too.”
Most patients have improved function and less pain after they taper off opioids; they are grateful to “get their lives back,” despite their initial fears of dose reduction.
“Chronic pain can be exacerbated by something called central sensitization (CS),” said Dr. Embry. “Basically, the brain begins to amp up its signaling via neuroplasticity, even though the ‘source’ of the sensation isn’t getting any worse.”
People with depression, anxiety and history of trauma are more likely to develop CS, but there are ways of lessening the pain — without the use of opioids.
“Learning cognitive behavioral strategies, moving and exercising, taking certain non-opioid medications, and changing other behaviors can reduce pain associated with these,” Dr. Embry said. “Opioids are not effective treatment for most chronic pain conditions and can make things worse in the long-term. However, opioids are very effective in the short-term for acute pain and for certain other conditions, so our intention is not to stop prescribing them, but to use them safely, where and when they are appropriate and effective.”