As a physical therapist, I quickly learned that pain was one of the most common reasons to seek out health care. Now, as a researcher, I try to figure out the best ways to relieve pain without using opioids or surgery.
Historically there has been little interest in non-drug treatments for pain relief. For suffering patients, this meant starting with a drug, often a narcotic, and if that didn’t work, then an invasive procedure.
With major changes in health care looming ahead, now is the time to ask how can that be systematically done.
First, short of a paradigm-shifting discovery, accept that relying on narcotics to relieve pain is not a viable strategy.
The past 50 years has seen a dramatic increase in the use of meds to treat pain, and the big picture evidence suggests diminishing returns. There are increasing rates of chronic pain in the United States, and back, neck and joint pain are leading causes of disability globally. Paradoxically, these poor returns occurred in an era of incredible advancements in other fields of medicine.
Normally the appropriate societal response would be to invest in more medical research. This would be a great strategy if chronic pain were linked to a renegade microbe, gene or cell receptor. But the complexities of chronic pain go well beyond that, which means that doubling down on traditional medication research to discover the silver bullet for pain relief is not going to solve this problem.
Second, it is important that future patient care models consider that pain is a symptom, a disease or a behavior. Each involves a different form of management.
When pain is a symptom indicating bodily injury or harm, there is a need to manage the injury and harm. Pain can also be an early indicator of an underlying serious disease, an important precursor to a definitive medical diagnosis and treatment plan.
But chronic pain is more than a symptom; it is also a disease characterized by alterations in the way the central nervous system processes signals. This is a relatively new development, and we know very little about the management of chronic pain as a disease itself.
In addition, pain has behavioral consequences like restricting physical activity or limiting productivity. Many times the initial behavior associated with pain is meant to be protective, but if the initial behavior continues it can actually be harmful.
Pain behavior can be influenced by many factors, including but not limited to gender, beliefs, emotions, cultural background, ethnicity and genetic predisposition. The behavioral consequences of pain are often ignored when people seek health care. Misinterpretation of whether pain behaviors are protective or harmful can lead to recommending unnecessary narcotics or invasive procedures.
So where do we go from here?
“Every system is perfectly designed to get the results it gets” — a quote often attributed to Dartmouth professor emeritus Dr. Paul Batalden — is a reminder that the rise in opioid misuse, addiction and deaths are directly related to the inability of our medical system to effectively manage common pain conditions.
Our existing health care system is designed to treat pain through easily delivered products, like opioids, injections and surgery. Its inability to adjust to the inherent individual nature of pain has caused tremendous societal problems.
Current debate on health care reform is focused on premiums, access and covered lives. These are vitally important issues in delivering care at a national level.
Unfortunately, debate about changes to the current delivery system that gave birth to the opioid crisis remain background noise. We can’t expect to make significant progress on improving pain relief by only dressing up the system’s front door.
Steven George is a professor and vice chair of clinical research for the Department of Orthopaedic Surgery and the director of musculoskeletal research for the Duke Clinical Research Institute.