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April 24, 2012

Transforming Pain Relief: The First Steps

Last month, The New England Journal of Medicine published a call to action for a “cultural transformation in the way clinicians and the public view pain and its treatment.” The authors, Dr. Philip Pizzo, dean for the Stanford School of Medicine, and Dr. Noreen Clark from the Center for Managing Chronic Disease at the University of Michigan, concluded that the scope of the problems associated with pain is “daunting” and that the limitations found within the health care community are “glaring.” They were speaking on behalf of their committee’s report for the Institute of Medicine, Relieving Pain in America, which — among other things — estimated that more than 116 million Americans suffer from chronic pain at an annual cost of $560-$635 billion. In other words, we are spending a ton of money on a growing problem that affects a huge portion of our population, and we are getting really bad results.

Creating a “cultural transformation” is no small feat, no matter what the subject or the circumstances. Isn’t that a term reserved to describe things like the Maoist revolution in China or text messaging and teenage social behaviors? It means a lot people all of a sudden start doing things in new and different ways with a common objective. Are doctors and pain sufferers up to this task?

Opportunities to fuel this transformation abound, and I think another one recently popped up with little fanfare in the pain management community. A large new study was just published in the journal Obesity showing a significant link between obesity and pain. This study was based on survey results of more than 1 million respondents, and the results suggested that the degree of obesity, based on the Body-Mass Index (BMI), correlated with greater levels of reported pain symptoms. Also of note, the research team showed that the relationship between pain and obesity persisted even after factoring in the effects of other chronic diseases like diabetes. This is by no means the first study to link pain with body size. For example, obesity has previously been shown to correlate with the severity of pain symptoms from arthritic joints, but any time a study comes out with a sample size this large, doctors at the front lines of treating pain should be compelled to take notice.

In no way does a study like this lead to the conclusion that obesity is what is causing the pain. It certainly begs for further discovery about how body weight impacts pain. Questions arise like which came first, the weight gain or the pain. Certainly, some patients report that their pain resulted in inactivity-related weight gain. We also don’t know that if two people sustain the same injury where one is obese and the other is not, whether or not the obese person is predisposed to experience more pain after the injury. It is hard to quantify how much subjective complaints are directly related to the calculated increase in mechanical forces created by excess weight, and we don’t know yet if the suspicious inflammatory mediators released by fat cells can directly affect pain.

Chronic pain is such a complex experience, based on so many different biological and psychosocial variables, that it can be really hard to tease out the impact of one specific factor (like body weight). I decided to crunch a little of my own data by taking a random sample of patients from our practice who are on prescription pain medications to see how many were overweight. This included 28 men and 18 women, and my results showed an average BMI of 30.3 for the males and 28.6 for the females. Based on CDC recommendations, a BMI greater than 25.0 is considered overweight and 30.0 or above is considered obese. In fact, only 12 percent of the men and 22 percent of the women in my sample had body weights within the normal range.

Where does all of this leave us with respect to the appropriately requested cultural transformation for pain management? Well, consider the analogy of where everyone who drank water from a particular lake came down with some type of stomach flu? Initially, we don’t know if it is the lake that is causing the sickness or even if the lake is contaminated with anything harmful; we just know the two events seem to be shared by the same group of people in a particular community. The association between folks drinking the lake water and getting ill could be purely circumstantial. Despite these uncertainties in cause and effect, the logical thing to do would be to alert the citizens about the situation and recommend that they stop drinking water from that particular lake, at least until things become clearer.

The logical thing to do as part of our pain management transformation is to make weight management an inherent part of pain education, treatment and prevention. Consider this an example of why pain treatment needs to shift from a primarily symptom management model, with a focus on things like medications and procedures, to more of a disease management model with measurable outcomes. This can be very hard to do when patients are coming to you because they hurt and want to see results quickly, and making lifestyle changes is a slow evolving process that isn’t expected to provide instantaneous relief. What makes this even more challenging is doctors typically don’t get the resources or the support they would need to actually create meaningful change. Most health systems don’t pay physicians much to spend extra time on nutrition and lifestyle counseling, not to mention all the support needed for things like followup phone calls and educational classes that would be needed to deliver lasting results.

Change can occur when we build accountability and rewards for successful accomplishments into the system. Imagine insurance plans paying doctors for implementing disease management programs to better control the impact of pain on society instead of ignoring these options? Perhaps they offer patients refunds for participating in value-based programs for things like weight management? If this can help pain sufferers feel better in the long run, then surely the insurance world will save money on treatment costs and medication use. In order to start the cultural transformation for pain treatment, we will have to establish benchmark measurements, and equip patients and providers alike with the resources necessary to create lasting results. Unfortunately, if we don’t know where we are going nor have a map to guide us, then we will continue to spin, directionless, while creating bigger and bigger waves.

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