Read Full Text: Providing chronic pain management in the “Fifth Vital Sign” Era: Historical and treatment perspectives on a modern-day medical dilemma (Free to access)
Journal: Drug and Alcohol Dependence
Year Published: 2017
Ranked 52nd on our 2015-2020 list of the 100 most influential OT-related articles
I’m sure most of us have experienced aspects of healthcare delivery that seem, shall we say, less than ideal.
Maybe you’ve found yourself wondering just how, on earth, we managed to get where we are.
How can our sophisticated healthcare systems sometimes lead to such poor care?
This week’s article is truly unique because it is a narrative review telling the story of one such healthcare failure: the opioid crisis.
And, let me tell you, this is a story of good intentions, unintended consequences, profit motives, deregulation, siloing, overreliance on small-scale studies, and short-term thinking—all of which ultimately created the perfect storm to create our current national opioid emergency.
Even if you feel your work doesn’t directly relate to the opioid crisis, I hope you consider spending some time with this article. It helps us understand the current state of healthcare, and perhaps you will find some ideas for how we can move forward.
The people impacted by chronic pain/the opioid crisis
Over 100 million Americans are living with chronic pain. (That’s nearly 1 in 3 people!)
The crisis outlined by this article is that the number of opioids prescribed to patients with chronic pain sharply increased in a very short time frame. In 1997, roughly 670,000 prescriptions were written for a new drug, OxyContin. By 2002, just five years later, the number had skyrocketed to around 6,200,000.
And, unfortunately, the number of opioid-related deaths followed suit.
Here is a Centers for Disease Control (CDC) graph of how the number of opioid-related overdose deaths has increased.
Today, it is estimated more than 130 people in the United States die EVERY DAY after overdosing on opioids.
The story of how we went from effective multidisciplinary care to the opioid crisis
As I mentioned above, how we arrived at these staggering numbers seems best described as a perfect storm. You will have to read the article for the full narrative, but I will do my best to highlight key points in the story arc.
The story begins with an optimistic time for pain management, and we even have a cameo from occupational therapy!
Around the 1950s, John J. Bonica, an anesthesiologist who is considered the father of modern pain management, started to take a more holistic view of pain than was typical at the time. We now refer to this as the biopsychosocial model. He designed a treatment program to match this more holistic understanding of pain, and he developed the first multidisciplinary pain clinic. The success of his practice caused the model to spread—and multidisciplinary pain clinics began to open across the country.
Guidelines stated that these clinics should involve comprehensive assessment and treatment that included:
- Physical exam
- Medication management
- Biopsychosocial evaluation
- Cognitive behavioral treatment
- Physical therapy
- Occupational therapy
- The ability to refer to specialists not offered by the team
And, the exciting news is that these clinics were deemed a success, with studies showing that they seemed to work. (Just imagine if we had continued to improve upon this model, how far we could be today!)
Ok, here’s where things get messy.
Here are some of the factors that led to the stark decline of multidisciplinary care—and the rise of reliance on opioids:
- CPT codes were introduced, which emphasized the fee-for-service model, rather than the holistic care package offered by the pain clinics.
- Managed care led to gutting pain clinics of certain team members. For example, certain specialties (like PT) became non-reimbursable in the pain-clinic model.
- With decreasing profit margins in their pain clinics, academic medical centers prioritized programs with higher profit margins (plastic surgery, orthopedics, etc.).
- Physician training programs began to emphasize more lucrative and procedure-based modalities, such as nerve blocks, ablations, and insertions of spinal cord simulators.
- The World Health Organization (WHO) recognized the treatment of pain to be a universal right.
- The American Pain Society ran an influential campaign, “Pain: The Fifth Vital Sign,” to raise awareness of the importance of pain management.
- The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated the assessment and treatment of pain for all patients in accredited settings.
- The JCAHO mandate gave little time to figure out the best options of pain management—and, with pain clinics having been closed all over the country, opioids were a cost-effective option which provided excellent short-term relief.
- There had been a long-standing fear of addiction to opioids, but two (extremely small) retrospective studies were circulated, which asserted that patients rarely develop opioid use disorder from prescription opioids.
- OxyContin was marketed aggressively to meet the need of pain management options, and even had FDA-approved labeling stating that addiction was “very rare.”
The saddest part of all, at least in my opinion, is that there’s no clear proof that opioids even do much good for patients at all. At the time of the writing of this article, there was NO conclusive answer to whether opioid therapy even improves patients’ outcomes at all. In fact, a systematic review found that there were NO well-controlled long-term studies (beyond 12 weeks) showing that opioid treatment controls pain and/or improves function.
But, we do know that opioid therapy comes with plenty of risks. These risks include:
- Overdose death
- Substance abuse disorder
- Fractures
- Sexual dysfunction
The providers’ dilemma
The article notes that this puts healthcare providers in a complex dilemma.
On one hand, we know that it’s important to treat chronic pain. After all, chronic pain comes increased odds of:
- Suicide
- Major depressive disorder
- Substance use and substance use disorders
But, we simply do not know, from a research perspective, what type treatment is best for chronic pain. And, we have to keep in mind that many patients do not have access to promising non-opioid options.
There are other treatment approaches that the article outlines which include:
- Non-opioid pharmacotherapies
- Physical therapy (OT was not mentioned )
- Psychological and behavioral therapies
- Complementary and alternative medicine
- Invasive pain management interventions
However, the research on the long-term effectiveness of all of these options is limited. And, the upfront costs are often higher, and the benefits take longer to manifest.
Recommended future directions
The article states that research is urgently needed to increase the evidence base of chronic pain management, to hopefully usher in a new era of pain management.
Here are the research questions they suggest:
- What are the safety and efficacy rates of using opioid medications for periods greater than 1 year?
- What are the system-specific needs and barriers of utilizing non-opioid therapies?
- What is the role of pharmacotherapy in combination with chronic pain management?
Takeaways for OT practitioners
(These are my personal takeaways, and were not mentioned in the article.)
Your skillset of holistic, long-term thinking is needed.
I was, of course, bummed that OT was not explicitly mentioned in the effective pain management strategies section.
But, the type of care the authors described as having the most promising research behind it seems very much within our wheelhouse. We are well-poised to approach pain from a biopsychosocial perspective. And, more than other professionals, we are skilled at helping our patients establish routines and habits that help minimize the impact of pain in their lives.
We are also skilled at setting up patients’ environments to address pain management and encourage participation in meaningful functional activities.
In my opinion, the best part about approaching pain from an OT lens is that our interventions are focused on long-term impact. That is something the healthcare system desperately needs when addressing pain.
We need to spend time examining the systems in which we work.
As OTs, many of us are rule followers. This skill has helped us succeed in the classroom, as well as complex work settings.
But, the reality is that rules and current systems are not always geared toward providing the best care possible for our patients.
Sometimes, our systems need to be re-examined. Reading through the story laid out by this article, one wishes that health practitioners had been able to more effectively sound the alarm at the right time. If only providers could have spoken up (and felt supported by management when doing so) when new systems and regulations led to the closure of those early pain clinics—the ones that had shown so much promise.
As OTs, we need to strive to provide effective care AND have sustainable business models for doing so.
One would have hoped that those early multidisciplinary pain clinics—which seemed to offer results and were backed by promising research—would have succeeded.
But, as we saw in this case, that didn’t happen.
Not because the care wasn’t working, but because the business model failed.
This story feels like a cautionary tale that sometimes the best care does not become the most widespread. That’s why I see this article as a reminder to remain cognizant of the business models in which we work.
At the end of the day, I see this article as a call to action for us as OTs: we need to ensure our care is effective, evidence-backed, and economically sustainable moving forward. And, as holistic thinkers, I honestly think OTs are uniquely equipped to meet that challenge.
Listen to my takeaways in podcast form:
Find other platforms for listening to the [OT Potential Podcast here.](https://otpotential.com/ot-potential-podcast)(Possibly) Earn CEUs/PDUs for reading this article
Many of you can receive continuing education credits for reading this article. Here’s a form 1 to help you do it, along with information to help you understand who qualifies.
And, here’s the full APA citation you many need:
Tompkins, D. A., Hobelmann, J. G., & Compton, P. (2017). Providing chronic pain management in the “Fifth Vital Sign” Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug and Alcohol Dependence, 173. doi: 10.1016/j.drugalcdep.2016.12.002