Chronic pain is epidemic in the United States, and the medical community struggles with finding solutions that do not involve the use of opioids. Case management strategies can help by teaching patients to self-manage their pain.
• The National Pain Strategy of 2016 offers suggestions for how to treat chronic pain.
• Pain psychologists help patients learn to cope with their chronic pain, and teams that include case managers can reinforce exercise, meditation, and other stress reduction strategies.
• Patients with chronic pain sometimes catastrophize, which ramps up the pain response. Case managers can teach patients how to stop this destructive cycle.
About one in five Americans suffers from chronic pain, and one in 12 experiences high-impact chronic pain. For the older, sicker, and frailer populations seen by case managers, those percentages likely are even higher. Yet the United States medical community continues to struggle with finding ways to solve this major health issue — and the problem worsened in the past decade because of the opioid epidemic.1,2
In addition to being linked to opioid dependence, chronic pain leads to restrictions in mobility and daily activities, anxiety and depression, and reduced quality of life.1
Plus, people see their doctors for chronic pain more than three times as often as they see doctors for other chronic illnesses, such as diabetes, heart disease, and cancer. (More information is available at: http://bit.ly/2AmEsXX.)
Pain management researchers and clinicians say a multifaceted approach is best. Patients can benefit from education, learning self-care strategies, and receiving psychosocial care.
The National Pain Strategy of 2016 creates a roadmap for transforming pain care in America, so it is a good place to start, says Robert D. Kerns, PhD, professor of psychiatry, neurology, and psychology at Yale University in New Haven, CT. Kerns also is director of mentoring and career development at the Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center at VA Connecticut Healthcare System in West Haven.
“The National Pain Strategy emphasizes this concept of pain self-management,” Kerns says. (For more information, see National Pain Strategy story in this issue.)
“It reinforces the idea that pain can be conceptualized as a problem to be solved,” he adds. “And it encourages people to have self-efficacy or self-empowerment to use what they already know to be true of strategies to help manage their pain.”
The goals are to manage underlying diseases and pain and to teach patients pain management skills that they can integrate into their daily lives.
Insurance companies and employers increasingly are turning to pain specialists to help patients with chronic pain. This is a return to where healthcare was 30 years ago.
“Many of us who trained in the 1970s did a lot of this work in pain management, and it was very popular, as research came out in support of it in the 1970s and 1980s,” says Michael Coupland, CPsych, RPsych, CRC, network medical director for Integrated Medical Case Solutions (IMCS) Group in West Palm Beach, FL. IMCS has 750 psychologists across the country, working in pain management for workers’ compensation organizations and others.
“Then, managed care came along and decimated these programs,” Coupland says. “The tool in the provider’s toolbox was to give medications; drug companies were saying, ‘You got to control pain as indicated by Medicare and guidelines, and here’s a safe way to do it.’”
Only, it was not safe. As the medical community learned in the past decade, opioid prescriptions led to many people becoming addicted and resulted in an epidemic of drug overdoses.
“Now it’s turning around, putting emphasis back on non-opioid interventions, and these are interventions with 40 years of evidence supporting them,” Coupland says.
The federal government is promoting non-opioid pain management, including a webpage by the Substance Abuse and Mental Health Services Administration – Health Resources & Services Administration (SAMHSA-HRSA) Center for Integrated Health Solutions. (http://bit.ly/2yPL5Qy)
The Center for Integrated Health Solutions promotes primary care providers collaborating with psychologists, addiction counselors, and pharmacists in managing pain. The webpage links to a checklist for prescribing opioids for chronic pain, noting that the benefits of long-term opioid therapy for chronic pain are not well-supported by evidence. The checklist also supports non-opioid medications, physical treatments such as exercise and weight loss, behavioral treatment, and procedures including intra-articular corticosteroids. (http://bit.ly/2EzKisR)
Psychologists help patients learn to cope with their chronic pain by teaching them techniques to stop catastrophizing and to change negative thoughts to affirmations, Coupland says. (See strategies for pain self-management in this issue.)
“Case managers can learn some reframing skills like how to take someone who is catastrophizing and settling down the catastrophizing,” he says. “Teach them positive affirmations: ‘I can cope with this pain.’”
It helps to understand how pain works: “The basic premise is that pain comes from a pain generator like a crushing injury to your fingers, which goes up your spinal cord to the brain where it is processed,” Coupland explains. “The brain decides how much threat this pain really portrays and takes action from it — such as pulling fingers out of the door.”
If the pain continues after the injury and tissues are inflamed, the brain sends some healing responses to that pain area. This process can be mediated by psychological factors, which is where pain psychologists can help.
“Some people filter the pain through their psychosocial factors like catastrophizing,” he says. “The brain thinks this is really terrible and ramps up the pain response.”
These response increases can result in guarding behavior in which the person freezes like a deer in headlights — not moving out of fear of the pain. This can make the underlying injury worse, causing disuse pain, he adds.
“People who previously had childhood trauma have compromised psychoneuroimmune responses, so their immune response is different from someone who didn’t have a traumatic experience before,” Coupland says. “For these people, their way of processing pain is counterproductive.”
Several decades ago, pain researchers and experts were talking about the multidimensional nature of pain and the importance of focusing on disease contributing to pain, Kerns says.
The idea of integrated care and case managers helping patients navigate their care was novel, he says.
Studies showed some benefits of using a variety of approaches to manage pain. These included exercise, massage, acupuncture, spinal manipulation, and other strategies.
“But the science was weak, and there was a lack of financial incentives for institutions to offer these services,” Kerns says. “That created a lack of availability, so those approaches were not generally available, and providers were not educated about these kinds of approaches.”
1. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults – United States, 2016. MMWR. 2018;67(36):1001-1006.
2. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR: Rec & Rep. 2016;65(1):1-49.