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Chronic Pain in Women: A Real Discussion on the Gaps in Care

October 5, 2021
The pain management community has enough reports on the gaps that exist in pain research, care access, and even opioids. Now comes the hard part–that is, implementing the proposed strategies and recommendations in day-to-day care.

Chronic pain in women was the focus of a HealthyWomen live webinar held in partnership with Practical Pain Management (PPM) on September 30, 2021. On the panel were:

  • Monica Mallampalli, PhD, senior scientific advisor at HealthyWomen and leader of its now Chronic Pain Advisory Council
  • Sean Mackey, MD, chief of pain medicine at Stanford University
  • Cindy Steinberg, national director of policy and advocacy at the US Pain Foundation
  • Christin Veasley, co-founder and director of the Chronic Pain Research Alliance

The core elephant in the virtual room was, why is there still not enough high-quality data available on the chronic pain experience, for both patients to understand their disorder and for clinicians to adequately treat the disorder? In addition, how can the multiple reports generated thus far (see below) on pain research, care and management make their way to the pain clinic and the patient in need? The panelists recapped what has been examined to date and how much farther we have to go to provide adequate care.

  • 2003 National Pain Care Policy Act (introduced in 2003 but never fully passed; parts were introduced in the 2010 Affordable Care Act)
  • 2011 IOM (now the National Academies of Sciences, Engineering and Medicine) report associated with the 2016 National Pain Strategy (NPS), which was developed based on Recommendation 2-2 of the IOM Report (Disclosure: Dr. Mackey and Ms. Veasley were on the oversight committee)
  • 2017 Federal Pain Research Strategy
  • 2019  HHS Interagency Task Force Report on Pain Management, led by Vanila A. Singh, MD

Below are a few brief highlights and a PPM follow-up with the speakers.

Another big pain report or task force is not needed. The pain management and advocacy community know what needs to be done – implementation needs to be next (Image: iStock).

Chronic Pain in Women – Key Points* from the Webinar

(*paraphrased)

 

Enough Pain Reports, Already

With regard to the reports cited above, Dr. Mackey noted they are just as relevant today as they were 10 to 15 years ago. “While some progress has been made, including terminology around high impact chronic pain (ie, pain interference or pain that leads to significant restrictions in activities of daily living, affecting about 8% to 10% of those with chronic pain conditions) – more resources are still needed. There still is quite a bit to do to advance strategic national goals,” he said.

Veasley commented on the Federal Pain Research Strategy gap analyses noting that recommendations on basic, translational, and clinical pain research were used to guide the programs included in the NIH HEAL initiative and its scientific recommendations. “There is often a lot of effort and funding put into developing these big reports, she noted, but what is needed afterward is a designated agency or body, along with significant funding, to bring all necessary stakeholders together to implement these recommendations in a coordinated fashion across systems…. We need changes in understanding, clinical behaviors and attitude, and actual implementation – in a coordinated way,” she added, noting that without adequate support on the back end, upfront focus can go to waste.

“That’s where we need people to speak up,” Veasley advised. “We don’t want to provide hope to those living with pain with a document and then see it shelved. That’s the message to take to Congress: stop generating more reports, and instead, take action.”

In fact, all four panelists agreed that another big pain report or task force is not needed. The community know what needs to be done – implementation needs to be next.

Progress is Progress, Even When It’s Slow or Unexpected

Steinberg highlighted a few examples of progress in the pain space that have been made, including a group of new migraine treatments (see also, the CGRPs) and Medicare’s recent additional coverage of acupuncture for low back pain.

More in today’s mindset, Dr. Mackey referred to telemedicine as the “silver lining” of COVID-19 – noting that virtual doctor visits have transformed healthcare delivery across medicine, including in pain management. He urged clinicians to continue to push for reimbursement/payments for telemedicine to be made equivalent to in-person care going forward.

Remember that Equal Access is Key

Veasley stressed the importance of continuing to focus on reducing disparities in research and care for women, but also for patients of different ethnic/racial groups and socioeconomic and geographic groups. Tailored treatments and real reductions in barriers to care do not exist yet. She called for a new  “research paradigm that always addresses diversity, inclusion, and equity (DEI) upfront rather than as an aside” or after-thought, noting that biologic, psychological, social and gender factors should also play a role in this shift. Understanding the individual experience of pain can lead to tailored solutions, she noted.

Time to Make Waves

Using substance use disorders as an example, Dr. Mackey pointed out that the reason national funds for addiction (think opioid use disorder, or OUD) got so much attention in the US in recent years is “because large groups of concerned citizens mobilized” and spoke up…. “Policymakers were being shouted out from across the country…. If that type of effort could be grown in the pain space,” he shared, “we could accomplish amazing things together.”

Women and Pain: Where to Go From Here

Individualized Pain Management

PPM: In terms of future initiatives, how do you see individualized pain management being fleshed out in a way that can be adapted to the clinician office? Is it possible or a lofty goal?

Dr. Mallampalli: It begins with understanding the biopsychosocial model of pain and how it can impact and help with individualized pain care. Provider education is important in understanding the biopsychosocial factors that influence pain. It is a lofty goal since we don’t know all factors that influence individual pain within the three domains, but we can start educating providers on the importance of delivering patient care from the lens of this model.

Veasley: It may not be an easy goal, but it is possible and it is being done for other complex diseases, such as cancer, where all aspects of the disease and its impact on all areas of a person’s life are taken into account and addressed through team-based care.

Collaborative Pain Care

PPM: Moving from bench to bedside can take years, but in terms of truly moving the needle from data to implementation, multiple things are needed, including clinical understanding, available treatments, care access, communication and collaboration, funding and reimbursement. If you could offer next steps toward implementation of the existing pain strategies, what would you recommend?

Dr. Mallampalli: From HealthyWomen’s point of view, the steps to take toward meeting the existing pain strategies include:

  • Raising public awareness of the National Pain Strategy (NPS)
  • Bringing attention to Congress about implementing the NPS, including necessary funding
  • Asking Congress for NIH accountability on what has been done to date
  • Example: After the NASEM published a report on opioids, it garnered support from 35 partnering organizations to form the Action Collaborative on Countering the Opioid Epidemic, which is responsible for bringing all necessary stakeholders together to implement the recommendations of the report.

Finding Answers in Other Medical Fields

PPM: It was noted in the webinar that borrowing from other specialties, such as neurology and psychiatry, has helped to move some pain treatments forward. Are there other gaps or areas to explore in this regard?

Dr. Mallampalli: Another example is neuromodulation. Perhaps we need a large database or a registry to capture this type of information from multiple disciplines. Many of the therapies that we use to treat pain are ones that are used in other spaces to treat complex brain diseases, such as depression. Medications originally developed for other conditions are often used “off-label” to treat pain, such as TCAs, SNRIs, and anticonvulsants. In addition, cognitive behavioral therapy (CBT) and other behavioral therapies (eg, mindfulness, stress reduction and relaxation therapies) used for sleep hygiene may help people with pain conditions improve their quality of life.

See also, PPM’s special report on the women changing pain medicine.

Last updated on: October 5, 2021
Continue Reading:
A Call to Action for Helping Women in Chronic Pain
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