Addressing the dual crises of pain and opioids — a case for patient-centeredness

 Addressing the dual crises of pain and opioids — a case for patient-centeredness
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Recent data suggest that health care is a top priority among American voters who will be heading to the polls. Pain is a health issue that touches all lives at some point, whether personally or through extended family. 

Caring for pain has become deeply intertwined with the opioid crisis. Though largely fueled by illicit opioid use, the opioid crisis has understandably spurred national and local organizations, as well as the public, to seek methods of pain treatment that carry the lowest risks. That in turn has led to policies that often emphasize limits on opioid prescribing.

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We must remember, however, that opioid limits alone do not constitute a pain care plan, nor do blanket opioid limits appreciate the individual differences across patients who live with pain. Over the past 15 years, the absence of patient-centered pain care contributed to an over-focus on prescribing opioids. Now, we are in danger of repeating the mistakes of the past by applying a one-size-fits-all regulatory “solution” that fails to address the specific needs of the individual and fails to treat their pain.

To be truly effective, our pain treatment programs and our policies should be evidence-based. They should be patient-centered. And, as one component of patient-centeredness, they should be accessible to those who need them. Three examples of ways to increase patient access to pain care include integrating foundational pain education into the trainings of all health-care clinicians, preserving access to physician-prescribed medication (including opioids when appropriate) and providing digital behavioral pain medicine to patients who cannot easily access in-person treatment. 

Research is the path to evidence-based care and legislative solutions. In a major step forward, earlier this year Congress approved billions in funding for the National Institutes of Health’s (NIH) HEAL Initiative, a trans-agency medical research effort focused on developing and investigating new and low-risk ways to treat pain, in addition to addressing opioid use disorder. This research promises to expand the options available to patients in the future.

We also need to make optimal use of the current therapies and prevention strategies we already have at hand. The Patient-Centered Outcomes Research Institute (PCORI) has invested millions in funding studies to determine which pain care therapies work best for different individuals, which strategies to prevent opioid use disorders are most effective and how best to deliver medication-assisted treatment to those with addiction. The resulting findings can further inform and refine pain management and policies on opioid prescribing and coverage of alternative pain therapies. 

The research that informs our policies and practices should reflect the realities of diverse patients and everyday situations. That may sound obvious, but traditional research has typically included carefully selected patients. Fortunately, research funders such as PCORI and NIH are supporting the inclusion of more typical, “real-world” patients in research so that the results will be more broadly applicable.

For instance, my team is conducting a PCORI-funded study on prescription opioid tapering that has few criteria that would exclude people with pain from participating. We are testing the comparative effectiveness of two common, evidence-based treatments to help manage pain during voluntary opioid reduction. People living with pain helped to design the study and are guiding its implementation.

Our national patient advisory board, comprised diverse representation across race, ethnicity and geographic location, is also guiding the research team. With this kind of inclusive approach, we expect that our findings will apply more broadly to patients in communities around the U.S., thereby increasing adoption of our methods and patient access to care that is acceptable to them.

As research and treatment become more patient-centered, our pain treatments will become more effective because they will be responsive to individual patients’ needs and circumstances. Pain care in the U.S. will be transformed when we focus on the right treatment, for the right patient, within a system that includes patients as true, valued partners.

Beth Darnall, PhD is a clinical professor at Stanford University School of Medicine, Department of Anesthesiology and Perioperative Medicine and is an NIH and PCORI-funded principal investigator of chronic pain treatment and patient-centered opioid reduction research. She has authored three books for patients and clinicians on behavioral medicine for chronic pain. Follow her on Twitter: @bethdarnall.