2014 Top Stories in Primary Care: Pain Management.

The most important development in pain management in 2014 has been greater scrutiny regarding pain medication use and misuse as well as greater attention paid to appropriate alternatives for the management of pain. We have known for some time of escalating issues including a three- to four-times increase in the number of overdose deaths since the 1990s related to pain medications. This rise seems to be the sharpest in groups such as the military and in women, with an overall estimate of 46 deaths per day from prescription painkiller overdoses in the US:

These finding were highlighted in the 2014 White House Summit on the Opioid Epidemic (http://www.whitehouse.gov/blog/2014/06/19/white-house-summit-opioid-epidemic) and have been followed by a shift in medication options to combat the problem. This has included the FDA rescheduling of hydrocodone to Schedule II, the approval of a new hand-held naloxone auto-injector to reverse overdose, as well as the November 2014 approval of an abuse deterrent version of hydrocodone:

The most significant change in policy has probably been the recent revision to the Joint Commission pain management standards (http://www.jointcommission.org/assets/1/18/Clarification_of_the_Pain_Management__Standard.pdf). The previous standards had been in place since 2000 and said very little about nonpharmacological approaches that should be considered. The new policy, which becomes effective January 1, 2015, states that:

“When considering the use of medications to treat pain, organizations should consider both the benefits to the patient, as well as the risks of dependency, addiction, and abuse of opioids.” More specifically, the Commission mentioned specific interventions to consider:

“Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. The following examples are not exhaustive, but strategies may include the following:

  • Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy),
  • Relaxation therapy,
  • Cognitive behavioral therapy, and
  • Pharmacologic strategies: nonopioid, opioid, and adjuvant analgesics.”

Of note, these recommendations are intended not only for inpatient settings, but “for the ambulatory care, critical access hospital, home care, hospital, nursing care centers, and office-based surgery programs.”

In addition to policy and regulatory initiatives underway, a number of publications have noted the need for a more comprehensive approach to truly reduce what is one of the leading causes of accidental or preventable deaths in most US states.1

This coming year will likely see more initiatives in this regard. What hopefully will come out of the discussion is a sharp reduction in overdose deaths. During this pendulum swing, which we have seen before in pain management, it is hoped that the care of those persons in pain is not sacrificed. To balance these goals, it is important to systematically improve the care options of those in pain by consideration, incorporation, and coverage of the integrative approaches outlined in the Joint Commissions report. In this way, we will not only have meaningful recommendations but meaningful pain relief.

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