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14 Articles in Volume 19, Issue #1
Analgesics of the Future: NKTR-181
Antidote to CDC Guideline; Plantar Fasciitis; Patient Input
Assessing and Treating Migraine in Women and Men
Demystifying Opioid-Induced Hyperalgesia
Editorial: Have We Gone Too Far? Can We Get Back?
How to Compel Patients to Complete Home Exercises
Inflammation Targeted Nanomedicine
Intravenous Stem Cell Administration for Ileitis
Invasive Surgery: Effective in Relieving Chronic Pain?
Pain Catastrophizing: What Practitioners Need to Know
Pain Therapy Options for the Home
Regenerative Medicine
The Future of Pain Management
Whole Body Vibration: Potential Benefits in the Management of Pain and Physical Function

The Future of Pain Management

Industry experts Jianguo Cheng, Stefan Evers, W. Clay Jackson, Lynn Kohan, William Maixner, Paula Marchetta, and more share their visions.
Pages 25-33
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As electronic health records merge toward integrated platforms, digital crosstalk will allow for more integrative care across multidisciplinary platforms. And as the fee-for-service model is supplanted by value-based models of payment, incentives among stakeholders will align toward desired patient outcomes, rather than competing for patient visits.

Opioid therapy will continue to wane, particularly as a foundational treatment strategy. If this change is accompanied by a concomitant increase in integrative, non-opioid, and non-pharmacologic therapies, patients will benefit. This will be the key advocacy battle of the next decade.

Training programs will evolve to reflect practice reality—they will be integrative, multidisciplinary, and technophilic. Although pain management teams will continue to be physician-led, they will cease to be physician-centric, focusing on exploiting the good ideas of all team members equally.

Lynn Kohan, MD
Associate Professor of Anesthesiology & Fellowship Director, Univ. of Virginia School of Medicine / Chair & Founding Member, American Society of Regional Anesthesia and Pain Medicine Headache Special Interest Group

It is an exciting time to be in the field of pain management. We are leaving behind the era of opioid prescribing and entering a time of novel and advancing treatment options including rapid advances in drug development, neuromodulation, and the progression of focused ultrasound. While the developments in these novel therapies are exciting, the treatment model is moving beyond the development of single new agents/techniques. Instead, there is increased recognition of the complex multidimensional nature of chronic pain that acknowledges the wide range of individual variations in susceptibility to pain, and of cultural and emotional responses to pain and responses to treatment, as Worley wrote in Pharmacy and Therapeutics in 2016.

Scientists are also beginning to have a better understanding of pain pathways and pain-related targets, and thus are able to develop medications and techniques to help alleviate pain with reduced side effects. Researchers are moving away from categorizing pain based on a particular diagnosis, injury, or anatomic location. There is a growing belief that thinking about pain in terms of nociceptive versus neuropathic pain may be an oversimplification, and thus researchers are increasingly focusing on identifying pain-related phenotypes, which incorporate detailed descriptions of pain (such as burning, stabbing, aching, shooting), as Van Hecke, et al, wrote in Pain in 2015. Identifying these pain phenotypes may result in a better understanding of the neural mechanisms of pain and thus allow for more targeted treatments.

In addition, we are on the verge of understanding more about the use of gene therapy vectors as a tool for the development of molecularly selective pain therapies, as Pletchia, et al, wrote in Mayo Clinic Proceedings in 2016. Advanced neuroimaging techniques are being used to examine the emotional and cognitive factors that can alter one’s pain perception in addition to the underlying neuroplastic changes that occur in response to chronic pain. For instance, functional MRI is being used to try to evaluate pain in real time and provide information about how pain may possibly be controlled. In addition, transcranial magnetic stimulation may be used to determine how various brain regions impact pain processing, according to Worley. These techniques, in addition to the use of biomarkers, may lead to a time of neuroprognosis—a field that may allow physicians to determine which patients may respond to one treatment versus another.

These advances, while some are still in their infancy, will likely contribute to the future of pain management. The goal of reaching the era of individualized pain management instead of trial-and-error techniques are within our grasp and are not inconceivable in the next decade.

PPM asked leading industry members and practicing clinicians to share what the pain management landscape may look like in the next 5 to 10 years. (Source: 123RF)

William Maixner, DDS, PhD
President, American Pain Society

Pain researchers are seeking a better understanding of the etiology of a variety of different pain conditions. When it comes to patient assessment, improved classification will lead to more personalized treatment for pain conditions. Individualized treatments will focus on interdisciplinary pain management protocols that follow a whole-patient focus.

There will be continued focus on reducing the use of opioids, and doctors will move away from routine prescribing of opioids in favor of combination therapies. New protocols will be followed for opioid weaning, and there should be greater utilization of cognitive behavioral therapies as part of interdisciplinary pain management programs.

Perhaps the most significant evolution of pain management strategy in light of regulations will occur from increased investments in pain research, such as the Helping to End Addiction Long-term (HEAL) Initiative. HEAL provides good resources for academia and pharma to work together in identifying drug candidates.

Paula Marchetta, MD, MBA
President, American College of Rheumatology

We will most likely see less and less use of opioids for the management of chronic pain, especially in view of the current opioid crisis and the changes in the regulatory environment as a result of it.

I think the team-based approach to managing chronic pain will become much more prominent. Both pharmacologic and non-pharmacologic therapies have long been used to help patients suffering from chronic pain. We often see that patients do best when several modalities are used in combination. Thus, the importance of the interdisciplinary team for coordinating care in pain management will become increasingly recognized by providers, as well as by patients. This approach allows different health professionals to combine forces in a structured way so that the pain management regimen for a specific patient can be customized and optimized.

With a team-based approach, there will be many more “touch points” for patient interaction with members of the interdisciplinary team. It will no longer just be the physician/prescriber taking care of the patient, but rather, pain management professionals working together will serve as resources to the patient for help and support.

Stephen L. Barrett, DPM, FACFAS
US Neuropathy Centers, Past President, Association of Extremity Nerve Surgeons

Last updated on: February 20, 2019
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