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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
Page 3 of 6

Looking specifically at lower extremity peripheral nerve pathology, I think pain management in the future will require not only an assessment of the actual pain generator/nerve pathology in the lower extremity but also its effect on the patient’s central nervous system (CNS). At this time, we are looking at patients with severe nerve pathology in their lower extremity from a global perspective. What is happening with their CNS and how we manage the peripheral injury with regard to that relationship will help us better understand what is happening from a central sensitization standpoint.

For example, a patient with 11 failed surgeries on their lower extremity is unlikely to be a successful surgical candidate on the 12th attempt. Today, clinicians are looking into functional MRIs of the brain, with referral to neurological specialists who can effectively treat brain pathology that is now recognized to be associated with depression, anxiety, and chronic pain. Implementation then can be instituted after neuronavigation is planned out with transcranial magnetic stimulation that successfully treats many of these psychiatric conditions. After the patient is treated for CNS pathology, we may begin to intervene with the lower extremity to reduce or eliminate the pain generator that was there in the first place.

Ultimate pain management requires a multidisciplinary approach and focus to treat the entire patient. In the future, and in some cases, even now, we will be able to accurately determine the true pain generator and to provide a comprehensive assessment of the patient, including their psychological status, sleep patterns, diet, nutrition, and metabolic status, pharmacological interventions, hormonal makeup, and exercise. Then, delivery of a customized treatment plan may be implemented.

David Cosio, PhD, ABPP
Anesthesiology/Pain Clinic, Jesse Brown VA Medical Center

There appears to be substantial dissatisfaction with the current state of pain management in this country among patients with chronic non-cancer pain. Psychology of the future will need to help address some of the sources of this dissatisfaction.

Psychologists can work to improve the delivery of pain treatment and ensure a strong future by:

  • helping to evaluate patients for comorbid mental health conditions
  • enhancing the efficacy of current pain treatment by
  • addressing common factors
  • helping to improve the communication between
  • patients and frontline providers
  • making treatment options such as Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), biofeedback, and hypnosis more accessible
  • evaluating the efficacy of current pain treatments through research.

It is when we view chronic pain from a biopsychosocial approach that we begin to understand the complexity of these conditions. It will be through continued education and the sharing of ideas across disciplines where we will witness a change in the field of pain medicine in the next decade.

Tina L. Doshi, MD, MHS
Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University School of Medicine

The future of pain management will underscore the diverse, multidisciplinary nature of pain, and the necessity of a diverse, multidisciplinary approach to pain management. The medical community has shifted away from the simplistic view of “pain as symptom” to a more sophisticated understanding of “pain as disease.” Pain is not just an unfortunate consequence of some other pathology; pain is the pathology, and there is now greater awareness that pain management needs to be just as comprehensive, coordinated, and customized as treatment for hypertension, diabetes, or cancer.

Over the next few years, we will continue to add better tools to the pain treatment toolbox. We will no longer need to rely on the blunt instruments of opioids and steroids, and can instead turn to more selective pharmacotherapies (eg, CGRP receptor antagonists, Nav1.7 inhibitors) and more refined interventional techniques (eg, high frequency and burst stimulation, regenerative medicine). Complementary and alternative approaches will also become increasingly accessible, as we – and payors – recognize the importance of evidence-based, non-pharmacologic, non-procedural therapies for the management of chronic pain. As we develop more, better pain management options, we will also need to develop a better understanding of which pain treatment options benefit which pain patients. Research into the genetic, epigenetic, and pharmacogenomic modulators of pain will help us to implement personalized pain medicine treatments.

Finally, we will learn how we, as individuals, can shape pain management. Our own diverse backgrounds, biases, and experiences have a strong influence on how we care for our patients, beyond the medications we prescribe or procedures we perform. We are entering a time where the clinician must possess a heightened degree of self-awareness to be an effective healthcare provider. Moving forward, we should aim to understand how our individual actions and interactions with each other create the context in which patients can find relief from pain.

Robert J. Gatchel, PhD, ABPP
Clinical Faculty, Department of Psychology / Center for Excellence for the Study of Health & Chronic Illness, University of Texas at Arlington

I believe we already know what the future of pain management will look like. As reviewed by Noe, Kishino, and Gatchel in 2017, there is no doubt that appropriately-administered interdisciplinary pain management is effective,and may be successfully used in the present epidemic climate of chronic pain in this country, as well as in other countries around the world. Unfortunately, in the past, the outcomes of such programs have been significantly diluted by the plethora of “pain clinics” that emerged but which did not offer true interdisciplinary care. In an effort to remain profitable, many such clinics reduced the number of personnel required to run an effective interdisciplinary pain management program. Moreover, many third-party payors lumped together these clinics with true interdisciplinary pain management programs without realizing the major differences between the two. Simultaneously, in their cost-containment zeal, the only programs payors focused on were the ineffective clinics that were not truly interdisciplinary in nature. In effect, they threw out the “baby with the bath water.” As a result, payors need to be educated concerning what true interdisciplinary care is so that they may make better authorization decisions now and going forward.

 

Last updated on: February 20, 2019
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