Real World Health Care Blog

Tag Archives: pain control

Pain Management: Opioid Adherence in Cancer Patients

This week, Real World Health Care speaks with Salimah H. Meghani, PhD, MBE, RN, FAAN. Dr. Meghani is an associate professor and term chair in Palliative Care at the University of Pennsylvania School of Nursing. She is also associate director, NewCourtland Center for Transitions and Health. Her main research interest involves palliative care, specifically understanding and addressing sources of disparities in symptom management and outcomes among vulnerable patients.

We asked her about her study on analgesic adherence and health care utilization in outpatients with cancer pain, recently published in Patient Preference and Adherence. We also discussed the role of non-pharmacological approaches in treating cancer pain.

Opioid Adherence Patterns

Real World Health Care: Last year, you published an article: Patterns of analgesic adherence predict health care utilization among outpatients with cancer pain. Can you provide a brief summary of the article and talk about the study’s implications for cancer patients with pain management issues?

Salimah H. Meghani, University of Pennsylvania School of Nursing

Salimah Meghani: This is the first study to understand how opioid adherence patterns, over time among cancer patients, relate to health care utilization outcomes. We used objective measures of adherence (Medication Event Monitoring System – MEMS) and novel adaptive methods recently validated by the co-author, Dr. George Knafl from UNC-Chapel Hill. We found that inconsistent adherence patterns of analgesics over time was significantly associated with hospitalization over a 3-month observation period. The interaction of inconsistent adherence and strong opioids (WHO step 3 opioids) was one of the strongest predictors of health care use. It should be noted that this was a serendipitous finding. We did not plan to study adherence patterns and health care utilization. It therefore needs validation in hypothesis-driven study.

RWHC: Are you currently involved in any new research programs studying pain management in cancer patients? If yes, can you briefly describe?

SM: Yes, I am studying outcomes of opioid adherence and adherence patterns among cancer outpatients. This is an important topic as few recent U.S. based studies exist on the topic despite all the recent guideline contentions (e.g., CDC guidelines for managing chronic pain including chronic cancer pain and ASCO response) and national policy debates on opioids.

How Patients Manage Cancer Pain

RWHC: What do you think are the biggest challenges facing researchers studying pain management in cancer patients? How can those challenges be addressed?

SM: One of the biggest challenges is that we know very little about how patients manage their cancer pain. We know that opioids are widely prescribed, but we also know that there is poor adherence to prescribed opioids. Other treatments such as acupuncture are not consistently covered by health insurance or lack data on clinical effectiveness. There is a need to understand how patients are managing their cancer pain and what health care systems can do better to address the great burden on unrelieved cancer pain. Future work should also include improving access to effective non-opioid treatments for cancer patients. My previous research has also documented racial and ethnic disparities in cancer pain treatment for African Americans, which requires continued attention.

Safe Opioid Use

RWHC: What do you think are the biggest challenges facing clinicians treating pain in cancer patients? How can those challenges be addressed?

SM: There is a lot of confusion among clinicians about the role of opioids and the safe and rational use of opioids among cancer patients. Unfortunately, there is little empirical evidence base about the outcomes of opioid treatment among cancer patients. A look at the recent CDC guidelines on managing chronic pain would indicate that cancer patients frequently, if not invariably, have been excluded from the studies of the outcomes of chronic opioid therapy. More empirical evidence is needed to help clinicians develop comfort in opioid prescriptions.

Non-Opioid Treatments

RWHC: What do you think is the role of non-pharmaceutical pain management therapies for cancer patients? How can clinicians integrate both pharmaceutical and non-pharma therapies for cancer patients?

SM: I think access to non-pharmacological treatments is the biggest problem. While the NCCN guidelines for cancer pain identify a number of non-pharmacological modalities, they are not readily accessible to cancer patients. I have argued this in a recent letter to JAMA Oncology about the CDC opioid guideline that recommends that non-opioid treatments should be the first line therapy for chronic pain. This paradigm assumes easy and consistent access to non-opioid treatments. Also, access to effective non-pharmacological treatments are very different among poor, minorities, those with limited literacy.

Global Disparities

RWHC: What initially attracted you to this field? What continues to inspire you about it?

SM: My original research interest was global disparities in opioid availability for cancer pain management and the role of the International Narcotics Control Board. After migrating to the United States, I became familiar with racial and ethnic disparities in pain care and the toll it has for patients and families. This work continues to inspire me.

Multiple Sclerosis: Overcoming Pain

Real World Health Care continues our series on pain management by speaking with Dawn Ehde, PhD, Department of Rehabilitation Medicine, University of Washington School of Medicine. Dr. Ehde serves as a clinical psychologist and professor at UW. She conducts research evaluating the efficacy of various behavioral, exercise, and pharmacological interventions for chronic pain, depression, and/or fatigue in adults with multiple sclerosis (MS) and other acquired neurological conditions.

Dr. Ehde discusses some of her recent clinical and research work on cognitive-behavioral interventions for MS-related pain.

Living with MS and Pain

Real World Health Care: In 2015, you published an article: Utilization and Patients’ Perceptions of the Effectiveness of Pain Treatments in Multiple Sclerosis. Can you summarize the key results of your study and the implications for patients with MS?

Dawn Ehde, PhD, University of Washington School of Medicine

Dawn Ehde: We conducted this survey to learn more about pain management from the perspective of people living with MS and pain. We found that people with MS and pain try a lot of different treatments to manage pain, but few treatments provide adequate pain relief.

Nonprescription medications such as nonsteroidal anti-inflammatories and physical modalities such as massage were some of the most common methods used. Many use more than one treatment to manage pain. Some of the treatments that individuals rated as most helpful, such as hypnosis, were infrequently used. In fact, we found that very few people surveyed had tried or accessed behavioral pain treatments such as training in mindfulness meditation, cognitive behavioral self-management, or self-hypnosis. This was the case even though there is good evidence that these types of treatments are beneficial to many people with chronic pain, including MS, and have few or no negative side effects. This study highlighted for me the need to improve access to these types of non-pharmacological pain management.

Integrated Care Approach

RWHC: Are you currently involved in any other research relating to pain management in MS patients?

DE: We have several studies in various stages that address pain management in MS. We recently published a study that found that an eight-session telephone-delivered self-management intervention was effective in reducing pain (both its severity and its interference with activities) and fatigue. It also was effective in improving mood, quality of life, and resilience. The benefits were maintained at 6- and 12-month follow ups. Patient satisfaction with the treatment was high as well.

The study I am most excited about is the MS Care study, which is a comparative effectiveness trial that evaluated the benefits of an integrated care approach to pain and depression management in the clinic called “collaborative care.” The MS version, called “MS Care,” aims to improve the quality of pain care in the clinic by adding an MS Care manager to coordinate care, deliver brief behavioral treatments, initiate or adjust other medical treatments, and ensure patients do not slip through the cracks. We also offer patients the choice of getting their care management by phone or in person. Seventy-five percent chose the phone. We found that patients with chronic pain and/or depression randomly assigned to MS Care had significantly improved pain and depression symptoms, including less severe pain, less interference, less disability, and less fatigue. Additional details on the results are available at http://www.uwmscare.org/background.

Opportunities in MS Pain Research

RWHC: What are some of the biggest challenges facing researchers who are studying pain management in MS patients? How can those challenges be overcome?

DE: I actually see a lot of opportunities as an MS pain researcher. The MS community is interested in improving pain management and supporting research in this area. For example, the National MS Society has named pain as one of its research priorities. We also often find people with MS are willing participants in our research, both as participants as well as stakeholders who guide us in our research. For example, we used stakeholders to guide our MS Care study. At times, we have had to work hard to convince potential funders that pain is an issue that warrants funding and study, but that has improved in the time that I’ve been doing research. We have come a long way since I first started in this area, when pain was not always recognized as an important problem deserving attention in MS.

Challenges for MS Clinicians

RWHC: What are some of the biggest challenges facing clinicians who are treating MS patients with pain management problems?

DE: MS presents many different symptoms to manage, and thus both patients and clinicians have a lot to discuss and manage in the typical clinic appointment. One challenge is that pain management is often only one of several issues being addressed. As such, it may be difficult to fully manage a complex issue like chronic pain. I think these challenges may be overcome by rethinking how we approach and deliver pain care. We need to look at harnessing technology — including telehealth technologies — to improve care. We also need to empower patients and the MS community to recognize that pain management is something that requires active self-management and multimodal strategies.

Pain Management Therapies

RWHC: What do you see as the most promising pharmaceutical therapies for treating pain in MS patients? What are the caveats that must be understood by clinicians when prescribing such therapies?

DE: As a psychologist, I’m less able to speak to promising pharmaceutical therapies on the horizon. However, I think there are promising practices for how we deliver pain care, including medications and other rehabilitation interventions. We did manage medications in our MS Care study, and our goal within that was to promote the appropriate and effective use of pain medications and other medications that can benefit pain management, such as some of the antidepressants which have analgesic benefits. We know from our research that too often, patients get started on a treatment, perhaps at a “low dose,” and for whatever reason, they don’t have adequate follow up to adjust, intensify, or change treatment plan. In the MS Care study, we closely and quickly followed patients’ pain and adjusted treatments to optimize their benefits or switched treatments if needed. We also know that physical activity — whether it is physical therapy or encouraging physical activity — benefits people with MS and likely helps with pain management.

RWHC: Do you see a role for non-pharmaceutical pain management therapies in treating pain in patients with MS?

DE: Certainly. This is where I’ve spent most of my energy, not only because I am a psychologist, but also because many people with MS want to use non-pharmacological therapies and strategies. The people with MS I know and our stakeholders are eager to advance our understanding and use of non-pharmacological treatments such as mindfulness meditation, relaxation, and cognitive behavioral coping skills.

Partnering with Patients

RWHC: What initially got you interested in this field? What continues to inspire you?

DE: I have had family and friends with MS, and thus was drawn to learning more about MS. I started out conducting chronic pain research in people where chronic pain such as headaches was the primary problem. When I started working with patients with MS clinically, I was struck by how little we knew about MS pain management and how people with MS pain were not accessing care we knew was helpful in other pain populations.

I’ve been inspired and continue to be inspired by the people with MS whom we’ve partnered with to conduct our research. Our best research has resulted from partnering with people living with MS. They’ve also taught me a lot about resiliency. Although MS can present many challenges like pain, many people with MS and pain live full, meaningful and happy lives.

I also have been fortunate to have training grants from the National MS Society, which have allowed me to train postdoctoral fellows in MS and rehabilitation research. They represent the next generation of clinical researchers in pain and symptom management in MS.

Calling for an Integrative Approach to Pain Management

This week, Real World Health Care continues our series on pain management with an interview with Bob Twillman, PhD, FAPM, Executive Director of the Academy of Integrative Pain Management. Dr. Twillman is responsible for overseeing federal and state pain policy developments and advocating for those supporting an integrative approach to pain management. He also serves as chair of the Prescription Monitoring Program Advisory Committee for the Kansas Board of Pharmacy. Dr. Twillman previously served as a faculty member at the University of Kansas School of Medicine, where he founded and directed the inpatient pain management program and was a co-founder of the hospital’s Palliative Care Team.

Improving People’s Lives

Bob Twillman, PhD, Executive Director, Academy of Integrative Pain Management

Real World Health Care: Can you describe the mission of the Academy of Integrative Pain Management?

Bob Twillman: Our mission is to improve the lives of people with pain by advancing a person-centered, integrative model of pain care through evidence-guided education, credentialing, and advocacy. In essence, we want to promote an integrative, multimodal, multidisciplinary approach to pain management because we believe such an approach is more effective and more cost-effective in treating all types of pain, both chronic and acute. Our educational opportunities teach clinicians how to provide this kind of care, and our advocacy efforts — which are unparalleled in the pain management sphere — promote policies that encourage provisions of this type of care.

Clinician Training & Challenges

RWHC: Why is it important for clinicians to be well-versed in integrative pain management?

BT: The traditional biomedical approach to pain management doesn’t always work well for a good number of people with pain. We know — and it’s been confirmed by the Institute of Medicine and in the recently-issued National Pain Strategy — that pain is a complex biopsychosocial phenomenon, and that an integrative approach is the only safe and sane way to care for people with pain. The only way to achieve the best possible pain control for every person with pain is to use an integrative approach that addresses all aspects of this complex phenomenon, as they play out for each individual person. There is no cookbook for pain care, and one size doesn’t even fit most, so we need to use an integrative approach that permits maximum flexibility in providing care.

RWHC: What are some of the biggest challenges that clinicians face in dealing with patients’ pain management issues?

BT: Undoubtedly, access to all the treatments we need in order to provide integrative pain care is our biggest challenge. Access to integrative non-pharmacological treatments such as acupuncture, massage therapy, biofeedback and others has never been good because insurance reimbursement is poor, causing people with pain to have to pay out of pocket for these treatments — something many of them can’t do. Adjunctive treatments such as physical therapy and behavioral health care might be more readily available, but they also are subject to inadequate insurance coverage that makes true access less than optimal. And now, even the medications that have been so ubiquitous as primary treatments of pain are under fire and both insurers and policymakers are restricting access to those as well. It’s really challenging to provide the kind of care that even key governmental agencies like the CDC have been calling for.

RWHC: How is the Academy addressing these challenges?

BT: AIPM continues to advocate for appropriate access to all of the treatments we need in order to provide comprehensive integrative pain care. Often, that means we have to battle inappropriate restrictions on pain medications, but we also advocate extensively for policies that promote improved access to non-pharmacological pain treatments. Recently, we have been advocating for enhanced Medicare and Medicaid coverage of integrative pain treatments, while also advocating for more opportunities to carry out Medicaid demonstration projects that we believe will show how much can be gained if those treatments were covered. And of course, we continue to educate clinicians about ways they can provide integrative pain care even if they don’t have a large multi-disciplinary staff and insurance coverage for all the treatments they need.

Pain Management Therapies

RWHC: What are the most promising non-pharmaceutical approaches for pain management and why are they important?

BT: Consider what the pain management experts at the Department of Defense and the Department of Veterans Affairs have listed as the five evidence-based, non-pharmaceutical approaches they think every current and former service member with chronic pain should be able to access: chiropractic and osteopathic manipulations, acupuncture, massage therapy, biofeedback, and yoga. And it’s important to note here, in follow up to my previous comment on inadequate coverage, that only some types of chiropractic and osteopathic manipulation are covered by Medicare, and only for some diagnoses. None of the rest of this list of five are covered.

Additionally, we know that many people with pain benefit from physical and occupational therapy and from behavioral health interventions. If we had full access with adequate insurance coverage for these treatments, we would be delighted. Being able to get these treatments for people with pain would mean that more of them would have less pain, better functioning in a number of areas, improved quality of life, and increased likelihood of being able to work. Plus, we would spend less money achieving those improved outcomes.

Opioid Addiction

RWHC: How is the rising opioid addiction issue in America changing how clinicians address and treat their patients’ pain?

BT: For much of the past two decades, pain treatment has been primarily associated with opioid prescribing. While I think increased opioid prescribing was a well-intended attempt by the medical profession to provide better pain care, it may have been misguided due to lack of evidence, lack of access to alternatives, and the influence of a number of market forces and cultural beliefs. Now that this increased prescribing has been implicated in the parallel and sharp increase in overdose deaths involving prescription opioids, policymakers are extraordinarily active in pushing legislation and regulation intended to reduce excessive prescribing. Unfortunately, this is happening in the context of the non-pharmaceutical treatment access problems I outlined previously, without concomitant attempt to improve that access. All of that leaves primary care clinicians, who deliver the majority of pain care in this country, struggling to figure out what to do.

We are hearing from people with pain that some clinicians are responding by either setting an arbitrary dose limit for opioids, or by establishing policies that they will not prescribe opioids, regardless of the circumstances. That may be harming people who benefit from those medications, in service of benefitting those who use opioids inappropriately and in a harmful manner. I think it’s going to be a while before all of this shakes out and we can arrive at a balanced approach that maximizes the benefits and minimizes the harms for everyone.

Pharmaceutical Industry Efforts

RWHC: What should be the role of the pharmaceutical industry in addressing the rising opioid addiction issue in America? How can they work with clinicians and groups like the Academy?

BT: The pharmaceutical industry has been engaged in efforts to make their products safer, by developing abuse-deterrent opioids. These medications make it much harder to abuse prescription opioids by means of altering them to permit snorting or injecting the opioid medication. This is an important step, because it will protect people who misuse these medications — the vast majority of whom are not people with pain. If we are able to do that, then perhaps we won’t see as much of a reactionary backlash that causes people with a legitimate medical need for prescription opioids to have their prescriptions denied or taken away.

The industry can also help us by increasing funding for our education and advocacy efforts. We have so many needs for education — both for new clinicians who are now in school and for experienced clinicians who are in practice — that meeting the need is an enormous and extremely expensive task. Due to mandates for Risk Evaluation and Mitigation Strategies (REMS) education imposed by FDA, much of this funding has been redirected away from organizations like ours that can provide integrative pain management education — and without discernible benefit. We desperately need FDA to revise the REMS program blueprints so we can teach clinicians about more than just the pharmacology of opioids and so we can teach about non-pharmacological approaches to pain care. It’s really challenging for the industry to adhere to FDA mandates and to go beyond those, but we need to find a way to encourage that to happen.