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    [BLOG]: Pain management: Can we balance patient access, safety and economic value?

    Srinivas Nalamachu MDNalamachu, MD In 2015, pain continues to be a conundrum for patients, practitioners, pharmacists, caregivers, long-term facilities, and payers. Balanced pain management is a comprehensive approach to diagnosing, treating, and controlling pain. It can include physical therapy and rehabilitation, psychological counseling, social support and/or medications, plus interventional procedures depending on an individual’s needs. Yet, many of our patients are not getting the care and relief they deserve, whether they suffer from acute or chronic pain. Unfortunately, we know from surveys that an estimated 40% to 70% of patients with chronic pain are not receiving proper medical treatment.1 Those with acute pain may face similar circumstances.

    There are many complex reasons why patients are not getting adequate pain relief. Three important considerations are: reduced access to medications perceived to have a high cost; safety concerns, including the abuse, misuse, and diversion of opioids; and limited access to integrated pain management, such as physical medicine and rehabilitation, complementary care, and psychosocial counseling.

    Related: How to develop drug formularies for pain treatment in women of reproductive age

    For the more than 100 million who suffer from chronic pain and untold millions with acute pain, access to appropriate, individualized pain management and clinical care is critical.2,3 Equally important is the safe use of medications when they are prescribed.

    As the population, especially the aging population, continues to grow, so will the national pain crisis. New strategies are needed to help improve access, outcomes, and medication safety.

    Pain and the role of multimodal analgesia

    One step in the right direction is to ensure hospitalized patients with acute pain have their pain resolved effectively and efficiently. If not treated effectively, acute pain can become chronic, and chronic pain patients use a substantial portion of healthcare resources.4,5

    Opioids are commonly prescribed for acute pain in the hospital setting. Although these drugs play an important role in the treatment of pain and are inexpensive in generic form, they can be associated with serious adverse events such as respiratory depression and bowel obstruction, as well as other complications such as sedation and dizziness leading to workplace accidents and falls. Ironically, hospitals may be over-relying on the use of opioids alone versus other pain management strategies, significantly increasing patients’ risk for adverse events and considerably driving up total costs with readmissions, longer stays, and additional care. According to data from a 2013 published study, total hospital costs for certain surgical procedures in which an opioid-related adverse drug event (ORADE) occurred were associated with a mean difference of $4707 more compared to surgical procedures without ORADEs. Length of stay associated with a surgical ORADE was 3.4 days longer than procedures without ORADEs.6

    Multi-modal analgesia (MMA), the combination of two or more analgesics to attack pain from different pathways in the body, may offer patients effective pain management while minimizing opioid monotherapy. The Joint Commission recommends MMA as a strategy to help avoid accidental opioid overuse7 and numerous professional organizations such as the American Society of Anesthesiologists, American Society for Pain Management Nursing, the American Geriatrics Society and Society for Critical Care Medicine, consider MMA a best practice.  

    Despite medical community support for MMA, some formularies rely on generic opioids instead, because they are so inexpensive. To achieve the best outcomes for our patients, we need to pause, carefully assess individual patient needs, and prescribe the proper course of care at the appropriate time for each patient. We also must have the ability to prescribe what we think is the best approach for each patient.

    NEXT: Access to and safe usage of opioids and alternative options

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