How Can the Intractable Problem of Chronic Musculoskeletal Pain (CMP) Be Effectively Managed? The Need for a Well-Integrated Systems Approach

Journal of General Internal Medicine, Apr 2018

Daniel C. Cherkin

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How Can the Intractable Problem of Chronic Musculoskeletal Pain (CMP) Be Effectively Managed? The Need for a Well-Integrated Systems Approach

How Can the Intractable Problem of Chronic Musculoskeletal Pain (CMP) Be Effectively Managed? The Need for a Well-Integrated Systems Approach Daniel C. Cherkin 0 0 Kaiser Permanente Washington Health Research Institute , Seattle, WA , USA - C the most clinically challenging conditions. The inability of hronic musculoskeletal pain (CMP) has long been one of clinicians to identify specific underlying causes of CMP for most patients and the lack of highly effective treatments continues to frustrate both clinicians and patients. Clinician desires to relieve their patients’ suffering in conjunction with patients’ often desperate demands for pain relief have led to increased use of invasive, costly, and higher risk treatments. Unfortunately, these treatments have failed to reduce the debilitating effects of CMP on patients1 and have been accompanied by significant adverse effects. Of particular concern has been the proliferation of opioid prescriptions that has devastated the lives of many patients, families, and communities.2 Fortunately, research has identified safe, effective, and sometimes cost-effective treatment options for the most common types of CMP.3,4 These treatments are now recommended as first-line alternatives to opioids and other pharmacological treatments.5 Because of the complexity of how health care is provided in the USA, trying to substantially change how even simple health conditions are managed can be daunting. This challenge is particularly great for CMP because it is an especially complex problem involving care from many disciplines that use a broad range of tests and treatments. Yet, because the current clinical approach to CMP has failed to meet the needs of many patients and had catastrophic effects on some, there is an urgent need to take strong actions to address this problem. It was with these concerns in mind that the 2011 IOM report on Relieving Pain in America concluded that Bto reduce the impact of pain and the resultant suffering will require a transformation in how pain is perceived and judged both by people with pain and by the health care providers who help care for them.^6 Transforming deeply entrenched beliefs, attitudes, and systems of care is essential if improving care for the tens of millions of Americans with CMP is to occur. Isolated and simplistic initiatives such as guidelines dissemination or restricting opioid prescriptions have failed to substantially improve care for CMP. Because numerous inter-related factors, including medical education, health insurance coverage, licensure and scope of practice legislation, and workforce supply, affect care for CMP, efforts to improve care will require a systems approach involving all key stakeholders. For a systems approach to succeed, however, it will need to be designed to address the unmet needs of both patients with CMP and the clinicians that care for them. A successful systems strategy will need to acknowledge the profound changes that have occurred in our understanding of chronic pain over the past two decades including the growing recognition that pain is not just a physical problem requiring physical solutions. The biomedical model of chronic pain is being supplanted by the broader bio-psycho-social model that recognizes that psychosocial factors are strong predictors of outcomes for the vast majority of persons with CMP whose pain cannot be attributed to a specific cause (e.g., tumor, fracture, infection). Recent neuroscience research has begun to provide a scientific foundation for understanding ways in which the brain (mind) and body are connected,7 highlighting the importance for clinicians to pay attention to the context in which patients’ physical pain occurs. For CMP and other conditions for which there are no highly effective treatments for most patients, non-specific effects, such as the caring shown by clinicians,8 may be stronger than the effects attributable to the specific treatment. There are a number of specific and coordinated actions key stakeholders could take to significantly improve care for CMP: IMPROVE MEDICAL EDUCATION FOR MANAGING CMP Primary care clinicians and other clinicians managing patients with CMP need to be trained to understand the importance of psychosocial as well as biological contributors to chronic pain and taught the skills necessary to identify and address patients’ needs (e.g., feeling heard, empathy and compassion, appropriate reassurance, and supportive referrals to effective resources and treatment options). These skills, which can be learned, are not specific to CMP but can be particularly helpful with such patients. However, effective use of these skills can only occur in environments that support their use by ensuring clinicians have adequate time with patients and easily accessible decision aids and educational tools. CHANGE MEDICAL APPROACH TO CMP It will be difficult or impossible for primary care clinicians to improve their care for CMP without improvements in medical education and relief from the often stressful practice conditions that undermine their ability to better meet the needs of their patients. However, there are a few relatively simple changes clinicians might make that could positively impact care. These include (a) focusing on understanding patients as well as their pain, (b) keeping up to date on the safe and effective treatments available to their patients, (c) informing patients that a number of safe treatment options that have been found effective for some patients and then partnering with the patients to find one that will work for them, and (d) encouraging patients to try activing treatments that help them learn and develop skills that can help them manage future episodes on their own. EDUCATE PATIENTS Like clinicians, many persons with CMP have an outdated understanding of the causes and treatment options for their pain and would benefit from access to reliable information that help bring these beliefs more in line with current knowledge. Furthermore, because persons with CMP often seek care from a variety of sources, they are often confused by the conflicting information they receive. Well-informed PCPs may be able to help patients understand the evidence regarding CMP, especially if supported by written or electronic educational materials and resources available in the community (e.g., groups for persons with chronic conditions). CHANGE HOW HEALTH CARE SYSTEMS PROVIDE CARE FOR CMP Although leaders of healthcare system have long been aware of the growing costs and poor outcomes of care for CMP, their attempts to address the problem have generally failed, largely because they addressed only a small part of the problem. To succeed, healthcare systems need to elevate CMP to a high priority, develop an understanding of how the system is failing to support clinicians in providing care that meets patients’ needs, and devote the resources necessary to achieve the desired results. Key elements should include providing primary care providers with a supportive environment that allows them to use the more time-consuming bio-psychosocial approach with their patients and exploring innovative alternatives or adjuncts to primary care involving clinicians with expertise in musculoskeletal pain such as physical therapists and chiropractors, or specially trained RNs. Systems need to lower barriers to the provision of safe, effective, accessible and high value care treatments and to raise barriers to less safe and effective treatments that continue to be the easiest to access. They then need to implement strategies to ensure their clinicians maximize use of the recommended treatments. ALIGN INSURANCE BENEFITS TO ENCOURAGE BEST PRACTICES Because changes in insurance benefits have not kept pace with the changes in clinical recommendations, policies are inadvertently encouraging the continued use of treatments that are less safe and effective than treatments recommended by clinical guidelines.3 Furthermore, a recent review found several Bcognitive and mind-body^ treatments cost-effective for chronic back pain and determined that the cost of providing such benefits would be very low.4 IMPROVE ACCESS TO SAFE AND EFFECTIVE TREATMENTS If health care systems and insurers remove barriers to treatment alternatives that have recently been found safe and effective for CBP, there will likely be an increased demand for providers of these treatments. To remedy this, institutions that train these providers will need to increase their training capacity. Because some of these providers are not licensed in all states, ensuring broad access to these treatments will require new licensure laws. CONCLUSION Using what we already know, there is a tremendous opportunity for greatly improving care for persons with CMP. This will require coordinated engagement by all parts of the complex Bsystem^ of care, including patients, clinicians, payers, educators, and regulators. The most fertile settings for the development and implementation of innovative approaches to improving care for CMP will likely be integrated healthcare delivery systems that have more control over changes affecting multiple components of the larger system and are better able to coordinate these changes. Among such systems, the VA seems particularly well-positioned to design, evaluate, and implement innovative strategies for improving care for CFP. The VA’s State of the Art Conference on Non-pharmacological approaches to Chronic Musculoskeletal Pain Management described in this issue provides a promising first step toward developing systems approaches to CMP that could serve as models for other health care systems. Corresponding Author: Daniel C. Cherkin, PhD; Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA (e-mail: ). Martin BI , Deyo RA , Mirza SK , et al. Expenditures and health status among adults with back and neck problems . JAMA . 2008 ; 299 : 656 - 664 . A published erratum appears in JAMA 2008 ; 299 : 2630 . Dowell D , Haegerich TM , Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain-United States , 2016 . MMWR Recomm Rep 2016 ; 65 (No. RR-1) : 1 - 49 . Chou R , Deyo R , Friedly J , Skelly A , Hashimoto R , Weimer M , Fu R , Dana T , Kraegel P , Griffin J , Grusing S , Brodt E. Noninvasive Treatments for Low Back Pain . Comparative Effectiveness Review No. 169 . (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No . 290 -2012- 00014-I.) AHRQ Publication No. 16 - EHC004 -EF. Rockville, MD: Agency for Healthcare Research and Quality; 2016 . 4. Institute for Clinical and Economic Review (ICER). Cognitive and Mind-Body Therapies for Chronic Low Back and Neck Pain: Effectiveness and Value , 2017 . 5. Qaseem A , Wilt TJ , McLean RM , Forciea MA . Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians . Ann Intern Med 2017 ; 166 ( 7 ): 514 - 530 . 6. IOM (Institute of Medicine). 2011 . Relieving Pain in America: A Blueprint for Transforming Prevention , Care, Education, and Research. Washington, DC: The National Academies Press. 7. Nijs J , Clark J , Malfliet A , Ickmans K , Voogt L , Don S , den Bandt H , Goubert D , Kregel J , Coppieters I , Dankaerts W. In the spine or in the brain? Recent advances in pain neuroscience applied in the intervention for low back pain . Clin Exp Rheumatol . 2017 ; 35 Suppl 107 ( 5 ): 108 - 115 . 8. Kaptchuk TJ , Kelley JM , Conboy LA , Davis RB , Kerr CE , Jacobson EE , Kirsch I , Schyner RN , Nam BH , Nguyen LT , Park M , Rivers AL , McManus C , Kokkotou E , Drossman DA , Goldman P , Lembo AJ . Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome . BMJ 2008 ; 336 ( 7651 ): 999 - 1003 . https://doi. org/10.1136/bmj.39524.439618.25

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Daniel C. Cherkin. How Can the Intractable Problem of Chronic Musculoskeletal Pain (CMP) Be Effectively Managed? The Need for a Well-Integrated Systems Approach, Journal of General Internal Medicine, 2018, 1-3, DOI: 10.1007/s11606-018-4362-5