President’s Message, January 2019

Ann Quinlan-Colwell, PhD, APN

As we enter this last year of the second decade of the 21st century, clinicians working with patients who experience pain confront the challenge of providing safe and effective pain management while facing numerous barriers to doing so. During the past few years pain management in the US has been dramatically affected by the opioid crisis. This is true for patients and clinicians alike. It is tempting to lament the resultant changes, barriers  and difficulties; however, without appropriate action such lamenting will only deter from working to improve pain management options and care. 

As I prepare to assume the presidency of the Southern Pain Society, I encourage us to set a goal to renew/redesign our efforts to optimize safe and effective pain management for all people experiencing pain.  An initial three-layered effort toward accomplishing this goal is to (1) clarify the barriers/issues that exist, (2) assess what is involved with them and (3) identify strategies to meet the challenges. Although there are numerous challenges, barriers and issues, I suggest we address the following during 2019. 

First, the current focus to develop standardized approaches, assessment, and plans of care is appropriate and effective when working with patients with many clinical diagnoses and conditions.  However, the challenge of utilizing a single standardized approach for managing all patients with pain is that pain is a highly complex and personal experience with a wide range of potential etiologies and complicating factors.  Trying to use a standardized plan of care for all patients, even those with similar diagnoses, is like issuing a single sized uniform to all employees working at an organization regardless of individual body size or measurement.  Pain management clinicians are challenged to educate and advocate organization administrators and health care colleagues to adopt patient specific multimodal approaches for managing pain.      

A second need is to provide accurate education regarding the various recent pain management guidelines.  It is imperative to understand that guidelines are simply “an indication or outline of policy or conduct” (Meriam Webster, 2018).  Thus, they are not mandates for prescription or rules or recipes for every patient experiencing pain. Rather, the guidelines are intended to provide guidance for clinicians when using professional assessment and critical thinking skills to provide optimal pain management for each person experiencing pain.   

An effective way to use guidelines is to incorporate them with ethical practice and the individual patient needs. The numerous patients who have been managing chronic pain for months or years with prescription opioids, need careful assessment.  Many patients who live with chronic pain have learned that certain opioids “are the only thing that helps my pain.”  Past experiences and the fear of pain may be paralyzing for such patients. Regardless of what any guideline may outline, if continuation of the opioid supports an individual to function at the highest level possible with minimal or no side effects, continuing the opioids at effective but not excessive dosing is ethically appropriate.  In such a case continuation of opioids supports autonomy of the patient while doing good and doing no harm, compared to discontinuation of the opioid causing deterioration of function and quality of life.  If, however, another person is concerned about opioid use and wants “to get off them” the clinician has the ethical responsibility to work with the person to utilize a multimodal approach to manage pain and reasonably taper opioids.  Caring for such a patient in that way also respects autonomy of the patient while doing good and doing no harm. 

At the same time, the ethical responsibility to prevent chronic pain needs to be highlighted and needs to be an important priority of future health care.  Clinicians need to be educated that unrelieved acute pain is a major cause of chronic pain.  Similar to current mandates of managing other conditions with the goal of preventing hospital acquired infections, health care organizations need to consider the multimodal management of acute pain with the goal of preventing chronic pain.  Primary care clinicians need to educate patients about the importance and how to prevent or minimize the likelihood of developing chronic pain through weight management, physical activity, flexibility training, good body mechanics and appropriate management of chronic diseases such as diabetes which may lead to chronic pain when poorly controlled.  All clinicians need to be educated regarding the valuable roles of non-opioid medications and non-pharmacologic interventions in managing acute pain as well as in preventing chronic pain.  

Efforts are needed to advocate for evaluation and subsequent reform of insurance company re-imbursement of non-opioid medications and non-pharmacologic interventions including cognitive behavioral and physical therapy consultations and follow up.  Clinicians need to advocate for enhanced financial re-imbursement for the time involved in providing individualized pain management both in general practice and among pain management specialists.  Advocacy is also need for government support of multimodal pain management efforts and pain management research.  It is imperative to remember the primary method of promoting the necessary changes in health care, including pain management, is through communicating with and voting for senators and representatives who will support the needed changes.

Finally, incumbent to achieving the essential changes needed to answer these challenges are for all clinicians who care for patients with pain to actively update themselves regarding new advances and education regarding multimodal pain management efforts.  The mission of the Southern Pain Society in part is to “increase the knowledge and skill of the regional professional community.”  From that perspective the Board of Directors of the Southern Pain Society works to continually provide education through our quarterly newsletter, twitter and Facebook communications, our new Speakers Bureau, and most excitingly through the innovative presentations at our annual convention which will be in New Orleans September 13-15 this year.  Finally, I invite you to contact us with any questions, concerns, or suggestions of how we can better meet your needs.  You are also invited to submit entries for the SPS newsletter and abstracts to present posters in NOLA.   Hope to see you there!