Current models of US health care delivery offer both obstacles to and opportunities for achieving quality and effectiveness in pain-related care, according to the keynote speaker at the 31st Annual Scientific Meeting of the American Pain Society (APS) in Honolulu. Daniel Carr, MD, Tufts University, suggested in his address that with health care system reforms anticipated, chronic pain is one of the most prevalent and costly conditions that needs to be addressed.
More than 1.5 billion persons worldwide experience chronic pain, according to the APS. In the United States, chronic pain costs up to $635 billion each year in medical treatment and lost productivity.
The preferred approaches to pain care delivery are evidence-guided, sensitive to individual variability, and focused on quality and achieving favorable outcomes, Dr Carr explained. In the future, he suggested, health care professionals committed to pain management will find it advantageous to align with the priorities of accountable care organizations (ACOs)-groups of health care providers who agree to link reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. Such priorities include avoiding hospitalizations and achieving other measures of quality and cost-effectiveness.
The ACO model rewards prevention; early detection; and interprofessional, team-based management in low-cost settings, such as primary care practices, Dr Carr noted. When ACOs work properly, they separate fees from services, encourage time to be allocated for patients with complex conditions, and support the use of less invasive treatments and behavioral therapies, he stated.
Dr Carr referred to the Institute of Medicine's (IOM's) 2011 report to Congress, Relieving Pain in America: A Blueprint for Transforming Prevention, Treatment, and Research, which made recommendations for improvements in pain care, education, and informing policy makers and public and private funders of health care that pain is a major national public health problem that must be addressed with aggressive action. The broad task for the IOM Pain Committee was to study the current state of pain research, patient care, and education and explore new approaches to advance the field.
The health care system needs to promote multifaceted, community-based care for pain rather than rely on a limited number of pain specialists, Dr Carr suggested. He explained that this public health approach involves defining a health problem, identifying its risk factors, adopting community-based intervention models to improve health outcomes in the target population, and monitoring effectiveness.
Other highlights of the APS meeting include the following:
• Training the brain to reduce pain is a promising approach to treating patients with complex regional pain syndrome (CRPS) and phantom limb pain, according to a researcher who spoke at the meeting. The brain stores maps of the body that are integrated with neurological systems that survey, regulate, and protect the integrity of the body physically and psychologically, stated G. Lorimer Moseley, PhD, professor of clinical neurosciences at the University of South Australia in Adelaide. These cortical maps govern movement, sensation, and perception, and there is growing evidence that disruptions of brain maps occur in patients who have chronic pain. The best evidence has been derived from those with CRPS and phantom limb pain, but there are data from patients with chronic back pain.
The research is focused on the role of the brain and mind in chronic and complex pain disorders. Through collaborations with clinicians, scientists, and patients, the researchers are exploring how the brain and its representation of the body change when pain persists, how the mind influences physiological regulation of the body, and how the changes in the brain and mind can be normalized with treatment. Disrupted cortical body maps may contribute to the development or maintenance of chronic pain and, therefore, could be viable targets for treatment, it was noted.
• Migraine is a neurological rather than a vascular disorder, and acute and preventive treatments currently being developed target both the peripheral nervous system and the CNS, according to a migraine expert who cited the latest genetic and biological research in addressing APS meeting attendees. Current acute migraine medications were developed to constrict cerebral blood vessels based on the prevailing concept that migraine is a vascular headache disorder, he noted.
Migraine often is dismissed clinically as a headache, but its genetic and biological basis is coming into focus as the result of scientific advances in recent years, stated David Dodick, MD, professor of neurology at Mayo Clinic in Phoenix. Now it is known that migraine is a largely inherited disorder characterized by physiological changes in the brain, and if attacks occur with high frequency, structural alterations in the brain.
Dr Dodick suggested that advances in migraine knowledge have led to the development of promising new and selective compounds and therapies for both acute and preventive treatment for patients with migraine. The basis for preventive treatment is understanding that underlying risk factors for migraine may be modified or eliminated before migraine attacks become more frequent, he noted, citing overuse of acute medications, depression and other mood disorders, obesity, snoring, head trauma, and excessive caffeine intake as major risk factors.
Migraine risk factors may be managed effectively in the primary care setting, Dr Dodick said, suggesting that physicians need to start thinking about the management of migraine in a disease model context, similar to that for hypertension or diabetes mellitus management. He noted, for example, that the risk of migraine is increased 5-fold in obese persons and increased 3-fold in depressed persons, suggesting that managing these risk factors is an effective prevention strategy.
• A 5-minute application of NGX-1998, a novel liquid formulation of high-concentration capsaicin, provides effective pain relief for up to 12 weeks for the management of peripheral neuropathic pain associated with postherpetic neuralgia (PHN), investigators reported. Capsaicin 8% (Qutenza) is available in a patch formulation that provides 12 weeks of PHN pain relief after a single 60-minute application.
For more information about the APS annual scientific meeting, contact the organization at American Pain Society, 4700 W Lake Ave, Glenview, IL 60025; telephone: (847) 375-4715; fax: (866) 574-2654 or (847) 375-6479; international fax: (732) 460-7318. Or, visit the APS Web site at http://www.ampainsoc.org.