Understanding the Complexities of Chronic Pain

By Jennifer New

Published on December 12, 2017

illustration of man with thread tangle within its headUI researchers are collaborating to improve pain education for health care providers.

“I remember my mother telling me that she was always in pain but just didn’t say anything because it didn’t seem like it would do any good. Now I understand what she meant,” says Pam Weest-Carrasco, a professional musician who had rotator cuff surgery last year. Although the surgery helped her to return to performing and teaching, she still grapples with daily pain.

She’s hardly alone. An estimated 25.3 million adults in the United States experience chronic pain—pain that lasts more than three to six months—and another 40 million adults experience severe pain, according to the 2012 National Health Interview Survey. Whether a result of surgery, an accident, or illness, chronic pain is often at the root of other life-diminishing problems, such as depression, anxiety, and insomnia.

In addition to being physically and psychologically difficult, chronic pain is also costly. People lose wages from missed work or spend money for treatments, either because they are under-insured or are seeking therapies that are not covered. Recent estimates put the total national health care expenses and loss of productivity due to chronic pain at between $560 million and $630 million dollars a year.

PAIN AND PRESCRIPTION OPIOIDS

The most dramatic losses are those stemming from the opioid epidemic, which accounts for lost lives, work, and homes. Research shows that overdose deaths involving prescription opioids have quadrupled since 1999. Today, nearly half of all U.S. opioid overdose deaths involve a prescription opioid, and in 2014, nearly two million Americans either abused or were dependent on prescription opioid pain relievers, the CDC reports.

One reason for this bleak state is an over reliance by health care providers on opioid prescriptions. Chris Buresh is a professor of emergency medicine in the University of Iowa Carver College of Medicine and a CPH alumnus (12MPH). He calls himself a “mid-career physician,” having graduated from medical school in 2001. Again and again, he recalls of his student days, “we were told that opioids were safe and not addictive, so don’t hesitate to prescribe them.”

Fast forward to 2017, and opioid manufacturers are now facing a deluge of lawsuits and investigations brought by cities, states, and counties for their alleged role in fueling the opioid crisis.

Keela Herr, professor and associate dean for faculty in the UI College of Nursing and director of the UI Center of Excellence in Pain Education (CoEPE), explains that the uptick in opioid prescriptions corresponds to a desire to achieve pain relief in a medical system that is allotting less time for health care providers to spend with individual patients; visits are sometimes as brief as seven minutes. Drugs are a solution that prescribers understand and insurers recognize, as opposed to other clinically proven approaches to pain management, such as mindfulness meditation or massage.

“The tendency for practitioners is to ask, ‘How can I relieve this patient’s pain with the time and resources available?’ And that’s often meds,” says Herr.

Buresh concurs that physicians are much more amenable to choosing the path of least resistance, noting that it’s been proven that physicians respond to systemic changes that make their lives easier. Historically, for example, the introduction of anesthesia for surgery was quickly embraced, as opposed to hand washing, which was perceived as time consuming and was resisted.

illustration of pill bottles and person with arms raisedASSESSING PAIN

Things are shifting, however. As both the public and health care providers become more aware of the severity of the opioid epidemic, there is a growing reluctance to rely on opioids. As a result, chronic pain is increasingly not treated, or under-treated out of fear of addiction.

“I advocate that each person needs to be looked at individually,” says Herr, whose research has long focused on pain in older adults. “There is a place for opioid use, if we are using them safely, evaluating risks, and monitoring patient use and outcomes.”

Those if’s are dependent on health care practitioners who are trained in assessing and managing pain. But this is rarely the case. According to the 2011 Institute of Medicine report, “Relieving Pain in America,” there was an urgent need for pain education to be improved for health care students at the undergraduate and graduate levels in order to address the health care system’s deficiencies.

Buresh says he received a few hours of pain education during medical school, which was mainly focused on the Likert scale, the 1-10 scale of pain that is ubiquitous to hospital rooms. As someone who now teaches emergency medicine to residents and also serves as the medical director for the Iowa Harm Reduction Coalition, it’s significant that Buresh doesn’t find this to be a very useful tool.

“Assessing pain is a constant source of frustration in the ER because it’s so subjective,” he says.

This variance in experience can cause people to doubt other’s pain in a way that we are less likely to doubt something that is measurable, such as a cancer staging. It also helps explain why medicating is a first reaction for health care providers who have too little training in the many factors that comprise pain.

IMPROVING PAIN EDUCATION

Directly improving education is the goal of the National Institutes of Health’s establishment of 11 university-based Centers of Excellence in Pain Education (CoEPE). The centers act as hubs for the development, evaluation, and distribution of pain management curriculum resources for medical, dental, nursing, pharmacy, and other schools to enhance and improve how health care professionals are taught about pain and its treatment.

The University of Iowa’s winning proposal to the NIH emphasized its existing strength in pain research across campus. Led by Herr in the College of Nursing, Tanya Uden-Holman in the College of Public Health, and Kathleen Sluka in the Carver College of Medicine, other project members are drawn from the School of Social Work and the College of Pharmacy.

Each of the CoEPEs is under an annual contract to develop one or two web-based educational pain case modules. Now in its third year, the University of Iowa has emphasized interprofessional approaches to pain management and developed three modules—each in web video form—on acute injury farm accidents with chronic pain, older adults with frozen shoulder pain, and total knee arthroplasty in older adults with osteoarthritis.

REACHING A SPECTRUM OF PROVIDERS

Laurie Walkner, a curriculum expert in the College of Public Health, oversees the actual creation of the training videos, collaborating with the lead case developer Dana Dailey, a physical therapist and assistant research scientist in the Carver College of Medicine. There has been a conscious decision to create materials that focus on some of Iowa’s health care strengths, Walkner says, including treating older adults and agricultural health issues.

“We really think about what competencies we should meet,” she says of the UI’s multidisciplinary CoEPE team. “The videos feature a spectrum of health care providers who would be involved with any of the topics, from the diagnosing physician, to nursing staff, to physical therapists and psychologists. Representatives from each area work with us to be sure that these cases reflect the questions and approaches that practitioners in those areas would utilize.”

The training modules follow a case from initial assessment through treatment, emphasizing different approaches to pain throughout. The team has tried to make them as realistic as possible, using actor-patients who are accustomed to working with medical students, and filming in skilled nursing centers.

The ultimate goal is for health care providers to understand pain in a much more multi-faceted way. Weest-Carrasco, the musician, says that she’s never had a single conversation about pain with any of her providers. “I was given a prescription and told to use it if I needed it,” she recalls. “That’s not really enough.”

This story originally appeared in the fall 2017 issue of InSight.