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10 Articles in Volume 16, Issue #5
A Review of Skeletal Muscle Relaxants for Pain Management
Applying Kinesiology as a Multi-Prong Approach to Pain Management
Arachnoiditis: Diagnosis and Treatment
Bench to Bedside: Clinical Tips from APS Poster Presentations
Conversation With David Williams, PhD, President of the American Pain Society
Letters to the Editor: Prince Fentanyl Overdose, High-Dose Opioids, Mystery Care
Los Angeles Times Versus Purdue Pharma: Is 12-Hour Dosing of OxyContin Appropriate?
My Experience With OxyContin 12-Hour Dosing
Technology: Changing the Delivery of Healthcare
The Neuroscience of Pain

Conversation With David Williams, PhD, President of the American Pain Society

Practical Pain Management sat down with Dr. Williams in 2016 to discuss topics ranging from funding for pain research to the role of psychology in treating chronic pain. Here is an edited version of that interview.

Q: What do you see as your biggest challenge taking on the role of American Pain Society (APS) president?

Dr. Williams: Well, whether it’s a challenge or an opportunity, I think that at no other time in history has there been so much attention publicly being paid to pain and its management. Whether the attention is coming from the National Pain Strategy, or the attention is associated with opiates and addiction, no one can say pain is not in the forefront of folks’ minds right now. That’s an opportunity for APS given that our members provide the science that supports solutions for better pain care.

David Williams, PhD

If there is a challenge associated with the high profile of pain these days, it is being able to move fast enough so as to fill our clinicians’ toolboxes with an array of multidisciplinary treatments that are effective for different forms of pain.

Q: How is the APS going to be working to help implement the National Pain Strategy?

Dr. Williams: One of the first things we’re doing is putting some money behind the National Pain Strategy. We have partnered with Pfizer to initiate a grant program (a $2 million grant from Pfizer).

The potential topics of the grant application are broad given that there are many different types of science that might support better pain care. The stipulation to the applicants is that each proposal must indicate what aspect of the National Pain Strategy is being addressed by the science being proposed.

Q: So the APS grants could be awarded to study any facet of pain, whether it be psychosocial or medical management or interventional?

Dr. Williams: Right. It could have a psychosocial component, it could be implementation of multidisciplinary treatment, and it could be educational—just so long as it is a hypothesis-based study that is relevant to the National Pain Strategy.

Q: Once these funds are awarded, what happens with the information; how long will it take from funding to final analysis?

Dr. Williams: These will be relatively brief studies, so we’re looking at a span of about 12 to 18 months. The studies can stand on their own, or may serve as precursor studies for larger multisite trials sometime in the future. The information from these studies will be peer-reviewed and then presented or disseminated at a future APS meeting and hopefully published in a peer-reviewed journal such as the Journal of Pain.

Q: You mentioned opiates and addiction. Is there one way to treat opioid addiction among chronic pain patients? Is there consensus on that?

Dr. Williams: I’m not an addiction specialist, but when pain is involved, it is important to make sure that the approach to pain treatment is best matched to the type of pain being experienced by the individual. Not all pain is responsive to opiates. When addiction is a comorbid condition along with pain, then both the pain and the opiate addiction need to be appropriately treated. These are two separate clinical problems.

Q: Does your group work with the other investigative groups from neurology, rheumatology, and gastroenterology? Is there cross-pollination of ideas?

Dr. Williams: APS is a multidisciplinary organization of clinicians and scientists. Many of our members belong both to APS and to their own professional organizations and present at both meetings so that there is cross-pollination of ideas across disciplines, if you will.

Historically, pain was studied in silos where you had rheumatologic pain, dental pain, cancer pain, etc. Where I think APS is a little different is that we study pain outside of the silos, which allows us to see commonalities as well as differences in the underlying pain mechanisms that occur in various regions of the body. When investigators from other specialties attend our meetings we often hear enthusiasm around opportunities to use new methods and to collaborate with people in other fields.

Q: This happened the other day [during the APS meeting]. The speaker on osteoarthritis was talking about pain, and she said, “You know, instead of giving them more of this [agent], then you might want to ask them how they’re sleeping. And if they’re having trouble sleeping, then maybe [they] should be referred to somebody to address [their] sleep issues.”

Dr. Williams: Right. As we learn more about how pain in general is processed, we are finding that many systems within the body can play a role in making it worse or better. It is becoming more important to understand the underlying mechanism of different forms of pain than, say, which body region seems to hurt.

Q: I know you’ve been studying the psychosocial connection between chronic pain, fatigue, fibromyalgia, and such disorders for many years. Are you happy with the meeting this year? It seems there are a lot of posters speaking to those issues.

Dr. Williams: There are. The nice thing about APS is that it is multidisciplinary, and so there is a lot of cooperation and mutual respect for medical and psychosocial/behavioral approaches to the study of pain and its treatment. I think that’s one reason why a lot of people enjoy coming to this particular meeting, because there is the feeling that everyone brings something to the table of chronic pain and its management.

Q: I was particularly interested in the role of early trauma on the later development of chronic pain. There have been a number of animal studies presented here that show that if you remove the baby animal from the mom and you isolate that animal, it will be more likely to develop chronic pain than an animal is left with the nurturing mother.

  The frustration that I hear from the primary care physicians is that this is all great news—we now know that depression, anxiety, and sleep disorders all contribute to pain. But how do the primary care physicians take this information and apply it in their practices?

Dr. Williams: If you are a primary care physician, you hear about things like cognitive behavioral therapy and exercise and physical therapy, but as an independent practitioner you probably don’t have all of these modalities readily available to your practice—yet you hear including them is best practice.

You can get access to some of the self-management approaches online—we’ve done a lot of work on developing fibromyalgia interventions that are behavioral in nature that are delivered online.

We have one called FibroGuide (fibroguide.com). It is basically the tenets of cognitive behavioral therapy that patients can access from their homes. Similarly, a clinic can recommend the online self-management program along with a medical prescription. The benefit of FibroGuide is that, like a medication, it has been subjected to randomized controlled trials and its efficacy is evidence-based. FibroGuide has demonstrated improvements in pain and physical functioning at levels that are comparable to medical management.

Q: And is this more like telemedicine?

Dr. Williams: Good question. There are static self-management websites that are called “unguided” websites, like FibroGuide, where there’s no therapist. Patients receive information in the form of text and video lectures from experts, and it has downloadable homework, etc. It’s a whole program, but there’s no therapist, so it is truly self-help.

Some people need a little more intensive care, and you mentioned telemedicine, where you actually involve videoconferencing or text messaging between the patient and a therapist. It can be done via telephone, it can be done with videoconferencing, and it is a bit more intensive type of intervention.

Q: And they’ve shown that the telemedicine therapy is actually very effective?

Dr. Williams: Yes. If you can’t have the one-on-one, this is the next best thing. And the outcomes are looking comparable to face-to-face with some added benefits of convenience (eg, you don’t have to travel to your appointment).

Q: There are about 100 million chronic pain patients, according to the Institute of Medicine. That’s a lot of potential clients for therapists.

Dr. Williams: It is, which is, again, why we’re really happy to see the National Pain Strategy come out, because this is the type of therapy that our organization [APS] has been pushing for years. Now we finally have a document to turn to and say this is the right way to be approaching pain care, and we want to provide the science that’s going to support doing this in the best way possible.

Q: Do you see any challenges from the patient perspective? If a patient comes in with chronic pain and the clinicians say, “I think you should see this person to talk about your condition,” do you get pushback from the patient?

Dr. Williams: There can be pushback, however, I think that patients are coming to clinics more informed, and they want alternatives. They don’t necessarily want to be always given a procedure or medication. Many people are asking for more quality of life options; they don’t want a lot of side effects; and there is a greater desire to be more in control of the pain management approach.

We’re seeing a broader range of expectations and a broader range of understanding of what’s relevant to pain management, and I think this is largely due to the fantastic work of patient advocacy groups. That said, it remains quite understandable that people with pain have the desire for it to go away as quickly as possible.

Q: Right. That includes coming to terms with the patient’s expectations for therapy. That the patient is not going to be pain-free, but [clinicians] are going to try to get you to be functioning on a higher level?

Dr. Williams: As a clinician, you certainly can’t guarantee someone will be pain-free. Early in treatment, however, you do want to understand the expectations for treatment both on the side of the clinician and that of the patient. What type of outcome is desired? What will that look like? How do you know when you have reached the desired outcome? With these fundamental expectations discussed up front, then the patient and the clinician have a basis for discussing how to best work together to achieve these outcomes.

Last updated on: December 7, 2017
Continue Reading:
Bench to Bedside: Clinical Tips from APS Poster Presentations

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