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Chronic pain treatment should go far beyond medications

There’s a lot of buzz surrounding the new non-addictive pain pill that is up for FDA approval. It works as well as opioids for treating acute pain, and shows promise in treating chronic neuropathic pain as well. We are constantly getting messages from patients we are treating for all different types of chronic pain — arthritis, back pain, fibromyalgia, and pain we just can’t seem to figure out — along the lines of “Doc, have you heard about it? When it’s available, sign me up!”

But treating chronic pain is so much more than a prescribed pill — even a non-addictive one.

For the millions of Americans living with chronic pain, it is easier, and cheaper for insurance companies if a doctor prescribes an opioid like oxycodone. Although opioid prescriptions have declined since 2019, rates of opioid overdose deaths remain stubbornly above 100,000 a year, even after a small decline in 2023.

What are health care providers doing to treat pain and suffering in America other than prescribing pills?

Last year, our 12-year-old patient Alex (not his real name), who was living with severe, chronic headaches, thought about suicide because, as he told us, “it would be better if I weren’t here.” Alex knew that his single mother was taking big hits financially due to his pain struggles and was worried they wouldn’t ever find the right care.

Relief from chronic pain is too often a result of luck and what’s in one’s bank account. And yet chronic pain — pain lasting for three months or more — affects many people: between 11% and 38% of children worldwide and more than 20% of adult Americans have chronic pain, with new cases of chronic pain occurring more often than new cases of diabetes, depression, and high blood pressure.

As a pain psychologist (E.R.) and a pain management physician (A.B.), we see first-hand that team-based, individualized approaches that emphasize all aspects of pain management — from medications and interventions to mind-body and behavioral strategies, group support, physical and occupational therapies, sleep, and nutrition — really work.

While our views as pain specialists may appear biased, the data and research are clear: not only do many of these strategies turn down the volume of pain, they also reduce reliance on opioids, ease suffering, help people get back to school and careers, and decrease hospitalizations. And though they may cost more in the short term, they save taxpayers and health insurers money in the long-term.

A no-brainer, right? Wrong. Although research shows that programs addressing physical, psychological, and social parts of pain for children and adults are effective, they are expensive, difficult to access, and clinicians aren’t paid what it costs to deliver these services.

To decrease disparities and raise medical providers’ and individuals’ awareness about the best opioid-free analgesic treatment, health insurers need to change how they pay for team-based pain care and prevent the disabling effects of pain. This may seem like a colossal feat, but it doesn’t have to be.

Even with the development of effective pain-related resources, we often hear “I can’t afford that” from our adult patients. Insurers rejecting coverage for treatment, high copays, and treatments that simply aren’t covered by insurance are pervasive. One of our 89-year-old patients with back pain and arthritis had recommended medical treatments denied by her insurer. Suffering from pain, she lamented, “I don’t know what right my insurance company has to practice medicine. They haven’t even taken the oath.” Contrary to the often-ambiguous insurance coverage guidelines and inaccurate AI-driven algorithms for approval or denial of care, there is no one-size-fits-all solution for treating chronic pain.

Lessons can be learned by the approaches used to treat severe chronic pain in kids, where bundled payments and negotiated insurance contracts allow children to benefit from interdisciplinary intensive pain treatment (IIPT). This type of treatment program typically takes place in an outpatient setting and lasts three to six weeks, eight hours a day, for five days a week. While in the program, kids with chronic pain receive daily doses of physical therapy, occupational therapy, psychotherapy, and recreational and music therapy by a team of providers who work together to coordinate care for each patient. Emphasizing the concept of “function before pain reduction,” the primary goal of IPPTs is getting children and families to the point where they are back to living life with pain or despite the pain — and rejoining their peers on the journey towards adulthood. Importantly, this treatment approach ultimately leads to pain reduction for many children.

Parents often tell us after completing our IIPT program at Boston Children’s Hospital things like “I finally have my kid back.” In fact, 85% of children completing our IIPT are functional and lead fulfilling lives five years later.

It took the persistence of passionate pain care advocates and institutional leadership to get insurers to sign on to paying for this program. Because of these financial barriers, 95% of patients currently treated at our program are white, English-speaking, and well-off, when we know that chronic pain affects people from all walks of life.

Successful pain management shouldn’t be reserved for the wealthiest or most informed.

Alex and his care team had to overcome many hurdles to get Alex back to a full life. It took a pediatrician who knew about our IIPT, financial assistance from his church community to pay for a long-term hotel close to the treatment center and, luckily, coverage by Medicaid.

To be sure, there are significant up-front costs to the IIPT approach. But the savings to insurers are substantial: our program at Boston Children’s Hospital, for example, significantly reduced the frequency of overnight hospital stays and emergency department visits, diagnostic tests, the use of medications (including opioids), and pain-related medical appointments one year after treatment.

When it comes to adults living with chronic pain, though, insurance companies are short-sighted and fail to acknowledge the science showing excellent long-term outcomes of this treatment approach.

We have seen how well the IIPT approach works. Pain treatment often also incorporates medications — and may someday even include the new non-addictive pain pill if it gets approved by the FDA — but goes far beyond that. Hospitals, clinics, providers, and patients must partner with insurers to listen to patient successes and heed the science, so that the best pain care is available to everyone — and not just those who can pay for it.

Antje Barreveld, M.D., is a pain medicine specialist and anesthesiologist at Newton-Wellesley Hospital in Newton, Mass., an associate professor of anesthesiology at Tufts University School of Medicine, and president-elect of the American Academy of Pain Medicine. Edin Randall, Ph.D. is a pediatric psychologist at Boston Children’s Hospital and an assistant professor of psychiatry and behavioral science at Harvard Medical School. The opinions expressed here are those of the authors and do not necessarily reflect those of their institutions.

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