Making Pain Management More Effective
September is Pain Awareness Month, a time to call attention to the challenges patients, clinicians, and other healthcare stakeholders face in managing pain, especially long-lasting pain that doesn’t respond to recommended treatments. Here at PCORI we are supporting a variety of research projects that compare the effectiveness of different approaches to managing pain, and we expect to soon fund several additional large, real-world studies in this area.
A Painful Problem
About 100 million adults in the United States suffer from chronic pain. That’s one in three adults, more than the sum of those with heart disease, cancer, and diabetes. The most frequent sources of continuing pain are the lower back, knees, and neck; severe headaches called migraines are also common. Chronic pain affects a person’s everyday life. It reduces productivity and quality of life, burdening not only affected individuals but also their families, friends, employers, and communities.
Chronic pain also affects the nation’s economy; the estimated costs of healthcare expenses and lost productivity exceed $600 billion each year. People with chronic pain annually lose, in total, half a million work days. As one of the most common causes of long-term disability, chronic pain presents a national challenge.
In many cases, only opioid drugs relieve chronic pain. In the United States. 5 to 8 million patients use these medications on a long-term basis. Prescription opioids can be problematic because they may lead to abuse or accidental overdose. Both the Institute of Medicine and the Secretary of Health and Human Services have called for individuals and society as a whole to change the way they think about pain and how it is managed.
Investing in Pain Research
Our Science Oversight Committee recently gave high priority to the challenge of improving chronic pain management. As a result, we held three simultaneous workshops to identify important comparative clinical effectiveness research (CER) questions that address opioid use in chronic pain, treatment for chronic low back pain, and systems approaches to improve the management of chronic musculoskeletal pain. Over 80 stakeholders, including representatives of patient advocacy organizations, healthcare payers, and research funding organizations, as well as patients, clinicians, and other care providers, attended the workshops and contributed to the discussion. PCORI staff are now refining research questions to consider for targeted funding announcements.
The importance of improving chronic pain management is already reflected in our research portfolio. Last May, our Executive Director, Joe Selby described some of this work in a keynote address at the annual meeting of the American Pain Society. Here, we highlight five projects we have funded.
Addressing Opioid Abuse
The number of deaths linked to abuse of prescription painkillers, like Vicodin and OxyContin, more than tripled between 1999 and 2012, according to the US Centers for Disease Control and Prevention. Yet, these medications are still widely prescribed to manage moderate to severe chronic pain.
In Washington State, we’re funding a project to evaluate an existing healthcare system initiative dedicated to reducing the risks of long-term opioid use by lowering dosages and increasing patient monitoring. By comparing 800 patients in clinics that have implemented the comprehensive multi-component program with 800 patients in other clinics that have not, researchers will learn how the initiative affects patient health and safety. They hope their findings will help patients and clinicians across the country reduce opioid dependence.
Alternative Treatment Methods
Recognizing that pain medications by themselves are often ineffective, many conventional healthcare settings are beginning to mix in fresh approaches to pain management.
A project in Rhode Island focuses on a novel integrated approach that encompasses massage, chiropractic therapy, and acupuncture as an alternative to opioids for patients in a state Medicaid program who frequently seek treatment at emergency departments. The study will see how a text-message-based program that includes enhanced patient navigation compares with standard advertising on measures such as patients’ engagement and retention in the broader state initiative, motivation to manage their chronic pain, and confidence in self-management.
A New York project seeks ways to make acupuncture treatments more accessible to underserved populations. About 700 patients in the Bronx, New York, will be assigned to one of two groups to receive 12 weeks of either individual or group acupuncture. The study will compare the two groups as to pain levels, quality of life, and other outcomes important to patients. If group acupuncture is as effective as individual delivery, it could reduce barriers to use of this approach to pain management.
Adding Behavioral Therapy
Psychosocial treatments, such as cognitive-behavioral therapy (CBT) and pain education, have shown promise but are seldom available to disadvantaged patients. An Alabama team recently developed CBT and pain education programs adapted to a low-income, low-health-literacy population. The team’s PCORI-funded project is comparing these pain education and CBT programs with each other and with usual treatment in nearly 300 financially disadvantaged, mostly African-American patients with chronic pain. The study will measure patient-reported pain intensity, interference in daily activities due to pain, depression, and self-reported overall improvement after treatment. (A feature on this project is available.)
According to the National Association of Community Health Centers, health centers have a particular interest in training primary care providers how to coordinate care with behavioral health professionals regarding substance abuse and pain management. The Alabama team has also received an Engagement Award to support an assessment of the behavioral health capabilities and needs of Alabama community health centers, from their perspective. The team will use this feedback to work with the state’s primary care association to conduct training in behavioral management of chronic pain for health centers. They will develop a learning community platform that can be then used for research collaborations between health centers and researchers in the state.
As one of the first trials in our Pragmatic Clinical Studies Initiative, a Pennsylvania project will compare two approaches to treating patients with acute low-back pain. The first approach is to provide primary care physicians (PCPs) with information regarding the risk of a patient with acute low-back pain developing persistent low-back pain and to allow the PCPs to do what they think is best. The second is to provide the same risk information but have the PCPs refer some patients—those who are at high risk of developing chronic low-back pain—to receive physical therapy augmented with cognitive behavioral coaching. The main goal of this project is to determine which approach is more effective at preventing chronic low-back pain.
Pragmatic clinical trials tend to be large and use data gathered in real-world settings rather than research facilities. These PCORI-funded researchers plan to collect data from 2,400 patients at 60 primary care clinics. In addition to measuring how many patients develop chronic low-back pain, the researchers will measure how patients in the study perform everyday activities such as sitting, standing, walking, lifting, and sleeping. The team will also compare the number of x-rays, magnetic resonance imaging studies (MRIs), and other medical procedures the patients receive for low-back problems.
We look forward to updating you as PCORI’s projects progress toward answering questions about pain management that are important to patients and the broader healthcare community.