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Introduction
New Imaging Tools Drive Chronic Pain Research and Understanding
NIH Director, Surgeon General Discuss Intersection of Pain Management and Opioid Crisis

NIH Director, Surgeon General Discuss Intersection of Pain Management and Opioid Crisis

With Francis Collins, MD, Director, National Institutes of Health, and VADM Jerome Adams, MD, US Surgeon General

The head of the National Institutes of Health and the US Surgeon General turned their attention away from the usual suspects to focus on lesser recognized problems in pain management and the US opioid crisis during a keynote at the 2018 NIH Pain Consortium Symposium. Held May 31 and June 1, 2018, in Bethesda, Maryland, the consortium was established to foster collaboration in pain research across NIH institutes and centers.

As part of their “fireside chat,” NIH Director Francis Collins, MD, and Surgeon General Jerome M. Adams, MD, MPH, discussed the need for: better use of existing pain treatments; implementation research to move promising discoveries to patients faster; a reduction in the dual stigma of chronic pain and opioid addiction; and improved understanding of disparities in pain treatment. Their discussion revealed a few themed recommendations.

Use all Modalities

“We aren’t using 90% of [pain management] modalities that are available,” said Vice Admiral (VADM) Adams. Part of the reason for this is that pain is often viewed as purely a physical problem. “If we simply look at it as a physical problem … then we’re not going to do an adequate job of treating pain.” Pain may involve strong mental, spiritual and emotional components, and until these relationships are better appreciated, chronic pain will remain under-treated, he added.

The connections between acute and chronic pain further contribute to the challenges faced by healthcare community. “I’m fond of saying that all chronic pain starts as acute pain,” said VADM Adams. We need to address acute pain to prevent it from becoming chronic pain, he advised.

VADM Adams and Dr. Collins agreed that, despite a wide range of existing treatment options for pain management (beyond prescription opioids), many approaches are not often used. Collins suggested that the treatment menu offered to chronic pain patients and the number of pain clinics has slowly decreased over time.

Get Treatments to Patients Faster

Researchers often focus on finding new modalities to treat pain, but identifying effective methods for getting those discoveries to patients is equally important. “Your discoveries don’t mean jack if they sit on a shelf,” VADM Adams playfully said to the audience of researchers. He told them to start considering how new drugs or treatments can be implemented as part of their research. He urged them to think about implementation as part of their research.

Better implementation strategies can translate into getting new pain management drugs and other tools into the hands of patients in weeks to months, not months to years, he stressed.

Collins admitted that reimbursement schedules through the Centers for Medicaid and Medicare (CMS) can be a barrier to getting treatments to patients. “We’ve been engaged in conversations with CMS about whether there is a way for us to build a stronger evidence base for pain treatment interventions that are not based on a pill, but are based on other [pain treatment] opportunities that we believe do show real benefit yet haven’t reached a point where CMS is willing to say they should be reimbursed,” he said.

These alternative approaches may include acupuncture and cognitive behavioral therapy, for example. Often, evidence for the utility of these modalities exists but the studies may not be as rigorous as for medications, he added. Clearer and perhaps more flexible evidence requirements may be needed to make these treatments more readily available and utilized.

Kill the Stigma

When Dr. Collins asked what else needs to be done to help patients with chronic pain and those struggling with opioid addiction, VA Adams responded without hesitation. “I believe that stigma is the biggest killer out there. Stigma affects our ability to respond to the opioid crisis. It affects how we deal with people with pain.”

He pointed out that Americans may have a somewhat unique mindset.  “Americans believe when it comes to pain that you should just suck it up.” He added that many think... “if you do happen to become dependent on a substance … you’ve got to figure out how to kick that habit on your own.” This mindset raises yet another barrier for individuals with pain.

Education is key to reducing this stigma, VADM Adams said. Researchers and clinicians have an important role to play in educating their communities about the myths and the facts. “You are respected leaders in your community,” he told the group. As such, researchers have the opportunity to educate and combat the perceptions around pain and pain management.

Recognize and Address Health Disparities

“I’m passionate about health equity,” VADM Adams said. Existing inequities may take several forms — urban versus rural, and minority healthcare, for example. “I think particularly when it comes to chronic pain, we need to very much get into and unpack how we got here, and how we disproportionately undertreat minorities for pain.”

Ironically, undertreatment of pain among minority groups may have had some protective effect against the prescription opioid epidemic for them. However, sad VADM Adams, “we also can’t ignore now that overdose rates for blacks, native Americans, and Hispanics are outpacing those for whites by far.”

Adams offered the treatment of minority patients with sickle cell disease (SCD) as a prime example of this disparity. SCD is common among African Americans and acute pain crises caused by the disease often leads patients to emergency departments. However, these patients are often labeled as drug-seeking and go under-treated.

“We absolutely need to unpack and deal with in a very intentional way the inequities that exist and the way we address chronic pain and the opioid crisis,” said VADM Adams.

Collins and Adams ended the discussion by acknowledging the dual challenges of improving pain care in the face of the opioid epidemic in the United States. The challenges are many but so are the opportunities for understanding how pain and addiction function in the brain, finding new non-addictive drug and device targets, making it faster to get novel therapies to patients, and educating clinicians and patients about other treatment options.

On a personal note, as reported in the media previously, VADM Adams shared that his younger brother has struggled with mental health issues and substance use disorders. Without consistent mental health and addiction treatment, his brother has been in and out of prison. “This [effort] is personal to me,” he said.

 
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