Rethinking Chronic Pain Management

Shorin Nemeth is a pain management specialist based in Portland, Oregon. He is currently a physician at Legacy Health, bringing extensive experience as a medical director in the healthcare industry. His expertise spans across program development, clinical research, medical education, palliative care and pain management.

Through this article, Nemeth argues for a comprehensive approach to chronic pain management, emphasizing coordinated care, addressing pain directly and avoiding overreliance on opioids.

Chronic pain remains one of the most prevalent and disabling diseases in our country. Time and again, the evidence has shown that treatment for this condition requires a coordinated team of specialists. If chronic pain is addressed correctly, it has been shown to decrease the total amount of money insurers need to spend on a patient over the long term. At Legacy Health in the greater Portland, OR and Vancouver, WA, area, I am lucky to be a part of one of the few remaining true team-based chronic pain programs accessible to all patients we serve. Other regional health systems have opted to offer injection-only models for their patients, leaving all other aspects of pain management up to primary care providers. In a city the size of Portland, OR, how can a dearth of multi-disciplinary pain resources exist?

Pain is seen largely as a byproduct of an untreated disease process. Logic will dictate that if we fix the underlying disease, the pain should subside. This same logic drove the medical establishment to focus more on the treatment of the disease rather than paying attention to the pain itself. Driven by an outcry from patients, in 1996, the American Pain Society embarked on a campaign to draw attention to the critical need to treat the pain. This started the “Pain as the Fifth Vital Sign” movement. This movement deemed the measurement of pain equally important as making sure the patient had a pulse and was breathing. Recognizing the need to highlight this cause, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a powerful organization that essentially dictates the standards of care for all major hospitals, developed standards for evaluating, tracking, and treating pain. Hospitals not following these recommendations risked losing their invaluable accreditation status. 

“Pain is seen largely as a byproduct of an untreated disease process. Logic will dictate that if we fix the underlying disease, the pain should subside. This same logic drove the medical establishment to focus more on the treatment of the disease rather than paying attention to the pain itself.”

In response to this JCAHO requirement, hospitals created processes by which any patient with a reasonable amount of pain would receive a pain treatment, usually an opioid. This devolved into some hospital emergency rooms providing patients with prescriptions for opioids at the time they were discharged from the hospital to ensure these patients would not unfavorably rate their pain treatment. Since opioids were very effective for treating pain short-term, they became a staple of treatment outside of hospitals and in doctor’s offices across the country. 

Healthcare in the United States is a business. In the business world, opportunity leads to innovation, which led the Sackler family to develop and aggressively market OxyContin, from which the “Opioid Crisis” was born. When opioids fell out of favor, the return on investment for prescribing medications for pain fell out of favor as well. Driven by a need to keep their clinics open, many pain specialists pivoted their practices away from the now less lucrative medication prescribing and instead only performed injections offering considerably higher financial reimbursement (epidurals, radiofrequency ablations, and nerve blocks). While injections can offer temporary relief for those suffering from chronic pain, moving patients from suffering from chronic pain to living a meaningful life with chronic pain takes a coordinated team of medical professionals. This includes physicians, advanced practice providers, physical therapists, psychologists, social workers, nurses, and others. In 2011, the Institute of Medicine of the National Academy of Sciences released “Relieving Pain in America,” which endorsed this model of care as a best practice. This multi-disciplinary model, which was the standard of care before the opioid crisis, succumbed to crushing financial losses once the Sackler family taught the medical community pills could address pain with far fewer resources.

While the opioid crisis has faded from the spotlight, it has left in its wake a specialty that cannot offer its patients the care they deserve without changes to reimbursement or technological advances to address the care gaps. Helping patients live with chronic pain involves far more than just prescribing opioids, particularly since we now understand chronic pain itself to be a disease. There are many non-opioid medications that can be used to help calm a dysregulated nervous system and address the numerous symptoms that co-mingle with chronic pain. However, subspecialty expertise akin to that of a Michelin-starred chef is required to understand how to use these pharmaceutical ingredients appropriately. To bring harmony back to the patient’s body and mind, the expertise equivalent to the level of the conductor of the New York Philharmonic is required to know which other medical disciplines are necessary. Because of the devaluation of these skills in favor of more lucrative injections, training programs across the country rarely teach these critical tools. 

With healthcare being a business and the profit margins for evidence-based care declining, the crisis that exists today in Portland and the rest of the United States is the question of, “Who will treat patients suffering from chronic pain?”