In the United States, 116 people die every day as a result of opioid overdose. While the U.S. only makes up 5 percent of the world’s population, it represents 80 percent of the world’s opioid consumption. It’s clear that there is not only an opioid epidemic, but also a pain epidemic. So how did we get here, and how can we better manage these two crises in tandem?
Our recent ARC Physical Therapy+ event Epidemic Intervention: Pain Management in 2019 tackled the complex issues around these two interconnected problems. Moderated by ARC Physical Therapy+ Chief Marketing and Acquisitions Officer Brian Stewart, the panel featured the following experts:
– Dr. Xavier Ng, MD, a Board Certified provider in Physical Medicine and Rehabilitation through his clinic, Core Pain Management
– Kimberly Sumner, MSPT, CSMT, the Director of the ARC Physical Therapy+ Overland Park, Kansas clinic
– Dr. Joshua Bunch, MD, a fellowship-trained spine surgeon with the Marc A. Asher Spine Center at the University of Kansas Hospital
– Gini Toyne, RN, MBA, CDMS, CCM, CLCP, founder of Gini Toyne & Associates Nurse Case Management Business
– Dr. Joseph Galate, MD, a physiatrist at Metro Spine & Rehab specializing in pain management and physical rehabilitation
We began the discussion looking at the roots and evolution of the issue.
Dr. Ng underscored the complexity of the problem and the shared fault at the bottom of it.
“Chronic pain is often misunderstood,” Dr. Ng said. “It’s different from acute pain, but we often treat it the same, and that’s the root of the problem. Acute pain is your body’s normal warning system telling you that something needs to be fixed. You can have a realistic expectation that you will heal and the pain will go away. Chronic pain is different. It lasts for long periods of time and is caused by other sources. It’s also closely linked to insomnia, depression and anxiety. In these cases, we need to address the whole person, not just treat the pain. The goal is not to get to zero pain. The goal is to make it so the patient can live with the pain.”
Dr. Bunch agreed that unrealistic expectations were a big part of the issue.
“The focus is on patient satisfaction, and if the patient has pain, they aren’t happy,” Dr. Bunch said. “That’s why it’s important to give people realistic expectations and educate them that pain control does not mean pain free. We want to get the pain level low enough that they can rehab, but we don’t want to put them in a dangerous situation, so there’s a fine line in controlling the pain. If we educate them and give them reasonable expectations, then they can be satisfied. We can’t tell them that they’ll be pain free. That’s not realistic.”
Dr. Galate lamented that the treatment protocol in workers’ compensation is seeing patients later and later.
“We used to see them 4-6 weeks after their injury,” Dr. Galate said. “Now, it’s 6 months out. By the time they get to us, they’re loaded up on narcotics, not in appropriate therapy, and they want me to fix them in two weeks. It’s not realistic. Primary care providers load the patients up with meds because they don’t have the knowledge or resources to do otherwise, but you can’t treat just one part of recovery, the pain. You need therapy and treatment to work on function. It also becomes more difficult to get approval and authorization on procedures that need to be done.”
Gini agreed with Dr. Galate about the difficulties of not seeing patients early enough, before they are stuck in the pain management cycle.
“As the nurse case manager, we have to have compassion, but it’s a fine line,” Gini said. “People are dealing with a lot of emotions and it’s harder when you get them late in the process. If we have an early intervention program as soon as the injury happens, we can help them faster. Complaining about pain and taking medicine doesn’t help. They need physical therapy and they need to get their mind on the right track with physical activity, sleep and setting expectations.”
Kimberly shared the value of education for the patient.
“When we see someone with chronic pain we spend the first evaluation, about an hour, on range of motion, and physical deficits,” Kimberly said. “We spend the other half on an assessment of what got them there. We educate them that some pain is normal, and tell them that we realize they are feeling pain, but here’s where the pain is coming from. We help them understand it at the patient level and share what they can do to minimize it.”
Dr. Bunch agreed with the approach of educating the patient and talking about expectations.
“I spend 30-50 percent of new patient visits talking about what I can improve and take away and what they should have in mind. I figure out what causes the pain and try not to jump to narcotics. Instead, I’ll try an alternative like steroids, an anti-inflammatory or medication for cramping. The more they know before they go into surgery, the more successful I will be as a surgeon.”
Dr. Ng emphasized the importance of treating the patient realistically and comprehensively to avoid the opioid crisis, especially when the typical patient has a high level of pain and is on a high level of narcotics.
“They are proactive about their pain meds and don’t want them taken away because they think it’s a pain issue, but really it’s an addiction problem,” Dr. Ng said. “If the pain is still at a 9 out of 10, then the meds aren’t working, especially when the patient is already taking more than what is recommended. With a holistic focus–getting them to exercise, try other types of pain meds, and get a good night sleep–then over time we can adjust their pain meds so that their withdrawal symptoms are negligible.”
The panelists expressed that not much time was spent on pain management during their education in school.
“I graduated in 2011 and even then, not that long ago, we spent very little time learning about pain management,” Dr. Bunch said, and Gini commented that she’s learned more in the last ten years on her own.
Kimberly has worked to educate herself through continuing education courses, learning about pain neuroscience and how to better educate patients.
“The more I educate my patients on why we’re doing exercises and give them the ‘why’ of how it will help them improve, the more successful they will be,” Kimberly said.
The conversation shifted to how providers can set patients up for success.
Dr. Ng stressed the importance of creating accountability for the patients and reminding them of the importance of sleeping well and daily exercise. “Once they see results, they are more likely to abide by the plan,” Dr. Ng said. “There are two constants in every pain program: exercise and a good night’s sleep.”
Kimberly mentioned the tried and true steps of setting expectations for the patient’s home program, reviewing the program with them, gaining their trust and putting the ball in their court to encourage patient responsibility.
“I tell them that they have to do the home program, or they won’t recover,” Kimberly said.
Gini agreed, noting she emphasizes with patients the importance of taking responsibility for themselves.
The experts then shared their main takeaway for attendees.
“I hope chronic pain is better understood in the future,” Dr. Ng said. “Opioids aren’t the problem; it’s how they are being used that is the problem. Because chronic pain isn’t being addressed properly, we are getting people addicted to opioids. The best outcome for the patient is also the least costly: early care and proper treatment.”
“The sooner we see the patient, the sooner we can take the fear out of movement and get them on the road to recovery,” Kimberly stated. “Education and being thoughtful about how we educate are also important. For example, we don’t want the doctor to overdo it with their assessment of the injury, saying, ‘This is the worst injury I’ve ever seen’ and things like that because it freaks the patient out and can impede their recovery.”
“The most important pieces are managing expectations, tailoring the treatment approach to each patient, and timely intervention,” Dr. Bunch shared.
“Early intervention in all areas is key,” Gini concluded.
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