Prescription for Abuse: Next Steps to Improve Pain Care for Washingtonians

DEC. 21, 2011
ByAlex Cahana, M.D.
Special to

Alex Cahana

Pain is hard. Hardest for those experiencing it, but also difficult for the well-intended healthcare professional, the educator trying to teach the difference between pain as a symptom and pain as a complicated disease, and for payers, administrators and policy makers trying to make informed choices.

But recognizing the problems are not enough. How do we ensure patients receive compassionate care in a way that is appropriate, effective, safe and financially sustainable for society at large?

There is no one way, but there are multiple ways that, taken together, can make a difference.

In 1961, John J. Bonica, father of modern pain medicine, opened the first academic pain clinic at University of Washington that became a world model for the diagnosis, study and treatment of pain. In 2008, proud to lead the legendary ‘Bonica’ clinic, I found myself stepping into a storm where dozens of providers asked to transfer care of their pain patients because ‘there was nothing else left to do,’ medical students decided not to pursue a career in primary care because they felt that ‘pain is too hard’ and Washington was one of eight states where deaths from accidental overdoses from opioids exceeded deaths from motor vehicle accidents. That required a new way of thinking and acting to improve pain care.

Pain care, as Dr. Bonica taught us, is a treatment plan devised by a multidisciplinary team that may sometimes include opioids, but always includes listening to the patient, determining the patient’s personal goals and individually tailoring a variety of medical, exercise, mind-body treatments, and healthy life choices.

We pay particular attention to the most vulnerable patients since the sickest and most disadvantaged are frequently those who receive the most pain medication, oftentimes because that is what their healthcare professional knows and what insurance will cover. As a result, these patients receive simply too much medication to be safe and to function well. There is no ‘good’ or ‘bad’ pain medication. There is only medication that is prescribed appropriately and safely, or not.

Our Telepain consultation video service connects dozens of healthcare professionals weekly for guidance and support. In 2011, more than 1500 physicians and other healthcare professionals discussed hundreds of patients and received hundreds of hours of free Pain education.

We have developed an innovative system for measuring and tracking key outcomes important to pain patients. We evaluate their mood, sleep, progress, intensity of pain and amount of relief they have experienced. These questions are systematically captured, tracked and analyzed so we can make more informed treatment choices for individual patients and provide advice for the greater pain population.

The UW Medicine Pain Center’s model of coordinated, collaborative and measurement-based care has been shared with medical practices regionally and nationally, with the Department of Defense, Veterans Administration, state agencies and large employers who are keen to develop value-based treatment plans for pain.

The new Washington State law 2876 offers guidance to healthcare professionals and defines the best time to seek expert help when patients do not do well. It addresses the need for TeleHealth, encourages providers to exchange prescription information and mandates the need to measure pain, mood and function at every patient-provider encounter. That provision, rarely mentioned or appreciated, is exactly what the 2011 U.S. Institute of Medicine (IOM) report on Pain Management refers to as ‘a needed cultural transformation.’ Measurement is key to understanding patients and the effectiveness of treatments.

Striking balance between access to affordable pain care and reducing risks of treatment-related harm is a delicate one.

Pain is hard. As a society we need to shift our thinking and recognize the complexity of this disease. We are off to a good start in this state, but there is much more work to be done.

Alex Cahana is Chief of the Division of Pain Medicine at UW Medicine.