PHYSIATRY, PHYSICIANS OF RECOVERY
Physiatrists are physicians who specialize in the care of individuals with functional deficits due to pain, disability, injury, and illness. Physiatric management focuses on the restoration of patient function and on safe, responsible, and holistic nonopioid strategies for pain treatment. Pain medicine is a common fellowship track for physiatrists, with increasing numbers of trainees choosing this subspecialty.16
Physiatrists are trained in the recognition and responsible treatment of painful musculoskeletal and neurological conditions. In addition, physiatrists have long known that the treatment of chronic pain should not be focused on pain reduction alone and must include a rehabilitation plan to improve function and quality of life while reducing exposure to harmful treatments such as opioids. Physiatrists are uniquely trained to lead and support a team of providers from many specialties. An integrated team can improve outcomes for patients with complex chronic pain—including pain that is often complicated by opioid misuse.21
Physiatrists are trained to provide optimal care for individuals with complex pain and disability. Physiatrists are taught effective diagnosis, assessment, and management of acute and chronic pain conditions including the use of medications, therapeutic and diagnostic injections, and psychological and vocational counseling.22 This includes understanding the etiology and clinical presentation of pain syndromes; demonstrating effective chronic opioid and nonopioid medication management (including management of addiction, tolerance, physical dependence, surveillance, drug testing); and serving as an expert resource in the multidisciplinary management of complex pain disorders.23
Collaboration with other medical providers in opioid addiction management is paramount, especially when patients with addiction have persistent chronic pain. Physiatric care is often administered in a multidisciplinary team setting that promotes quality of life and functional restoration.
Physiatrists receive explicit training in appropriate opioid medication management and are a resource for primary care physicians, surgeons, and other medical specialists to prescribe opioid pain medications when appropriate.3,18,24 Physiatrists are trained in the management of exercise, nonopioid analgesic medications, use of procedural treatments for pain, and recognition of conditions requiring surgery.
Physiatrists function in a critical “midfield” role in healthcare, directing and redirecting the flow of patients between often costly surgical interventions and preventive primary care.24 In this key role, physiatrists have a holistic perspective on pain management, coordinate the entire healthcare team from their midfield location, and possess a unique set of diagnostic skills, technical skills, and the judgment required to redirect the flow of patient care. Physiatrists collaborate with other healthcare providers along the entire spectrum of pain care. This includes collaborative management with primary care, surgical, and emergency medicine providers in the acute pain setting; with primary care, surgical, and specialty care providers, along with rehabilitation therapists and pain psychologists in the chronic pain setting; and with both primary care and addiction medicine specialists when patients with persistent chronic pain require opioid-minimizing and opioid-sparing treatments in the setting of opioid misuse.
Primary care medicine is often focused on health maintenance, efficiency, and population health, and primary care providers often have little direct training in musculoskeletal and pain medicine.25 Physiatrists, with their specialized training in pain management and in the diagnosis and treatment of musculoskeletal conditions, can function as a complement to primary care. Furthermore, when physiatrists are partnered with emergency medicine providers to manage back pain, there are 80% fewer “bounce back” cases (patients who returned to the emergency department within 30 days), with increased detection of dangerous disease and more appropriate medication use.26 When a physiatric consultation is provided before elective spine surgery, there are 30% fewer back surgeries with a substantial drop in overall cost and without disruption in patient satisfaction.27
Physiatrists are particularly skilled at identifying painful conditions early through expert physical examination, electrodiagnosis, and diagnostic testing. Physiatrists have the opportunity to provide care for patients shortly after injury and surgery and are trained in implementing effective acute pain management strategies. Physiatrists also evaluate and treat the psychosocial factors that contribute to chronic pain. The incorporation of physiatrists early in the treatment of acute and subacute pain and supporting them in the treatment of chronic pain is essential to address the opioid crisis.
THE IMPORTANCE OF AND LACK OF ACCESS TO NONOPIOID TREATMENTS FOR PAIN
The opioid crisis in the US can be attributed in part to the overtreatment of acute and chronic painful conditions with opioid medications.28,29 Pain treatment should be redirected to emphasize the nonopioid and nonpharmacologic interventions that physiatrists employ, minimizing the social and economic impact of addiction and opioid-related morbidity and mortality.30 Examples of nonpharmacologic interventions include heat, cold, acupuncture, manual treatment, durable medical equipment, braces, nerve blocks/ablation, spinal injections, spinal cord stimulation, exercise and movement, and behavioral treatments to emphasize the activities that improve function and quality of life. Nonpharmacological strategies often work best when employed synergistically, as part of a multifaceted plan of pain care, although more research to guide these treatment combinations is needed.
A major limitation to the use of nonopioid, nonpharmacological pain treatment strategies is lack of access. For example, despite the cost of chronic disability and the threat of the opioid crisis, patients typically have access to 20 to 36 physical therapy sessions per year, with copayments between US $10 and $50 per session.31,32 Uninsured individuals are charged US $50–$350 per therapy session.31,32 The high cost and limited access result in underutilization of physical therapy by Americans, despite its potential to reduce chronic pain, improve function, improve the chance of return to work, and decrease patient reliance on habit-forming pain medications.33 The negative cost consequence of inappropriate pain management should drive payment reform and enhanced access to appropriate treatments. Physiatrists can function to improve the utilization of exercise therapies while these policy changes are underway; physiatrists can diagnose the primary pain generators and provide targeted therapy prescriptions and home exercise programs that address patients' musculoskeletal ailments.
Furthermore, physiatrists are leaders in pain rehabilitation programs for complex and disabling chronic pain. These programs are intensive, often requiring 70 hrs or more of physical therapy, occupational therapy, pain psychology, physician visits, and exercise to show successful outcomes. These intensive pain rehabilitation programs have led to years and even decades of improvement in physical activity, decreased opioid use, improved mood, and decreased costs to health systems.34 Pain rehabilitation programs were financially challenged when low-cost opioid management became alluring. The false promise of large-scale opioid treatment for chronic and disabling pain is manifest, and the lack of access to pain rehabilitation programs for Americans is disheartening. Physiatrists are the most qualified professionals to lead patients to successful outcomes within these programs.
THE FUTURE OF PAIN TREATMENT AND THE IMPORTANCE OF RESEARCH AND EDUCATION
Enhanced funding of pain research is of immense national interest and should be driven by the need for safer and more effective pain treatments. The National Institutes of Health, which funds most of the basic biomedical research in the US, spent less than 2% of their annual $30-plus-billion budget on pain research before 2018 despite the fact that approximately one in ten Americans lives with chronic pain and pain is the leading cause of disability in the US.1,35 The National Institutes of Health received US $37 billion in fiscal year 2018 with opioid research targeted to receive a boost of US $500 million; opioid activity–related funding is earmarked to focus on addiction and nonopioid pain treatments. This research should focus on rehabilitation strategies, psychosocial needs, physical activity, and interventional procedures, all of which provide nonopioid options and may help reduce opioid use, improve function, and permit continued participation in society.
All clinical pain research should report function as the most important outcome of any treatment or intervention studied. Pain research should evaluate outcomes over extended periods. Receiving two or more opioid prescriptions after an acute back sprain is associated with a doubling of the patient's risk for long-term disability.31,36 Hence, even pain research in acute pain should include long-term patient follow-up and attention to function, impairment, and disability. Research should be framed by reformed health care delivery models that provide longitudinal access to appropriate multimodal care that is not anchored by opioids. Pain research efforts should target community strategies to educate the public on the safety profile of opioids and on the value of nonopioid approaches for treating pain.
Ultimately, providers are responsible for safe opioid prescribing and must be competent in opioid-sparing pain management. Medical education at all levels should expose trainees to the challenges that accompany the treatment of acute and chronic pain and incorporate the best evidence in a model that emphasizes rehabilitation. Medical education must incorporate evidence-based approaches to the judicious use of opioids and concurrent nonopioid therapies, along with training in physical medicine as well as in addiction medicine and in opioid weaning techniques. Training in physiatry is an excellent fit for these needs: The Accreditation Council for Graduate Medical Education requires that physiatrists entering into practice be well trained in the diagnosis, assessment, and management of patients with both acute and chronic pain conditions and effectively use medications, therapeutic and diagnostic injections, and psychological counseling in the treatment of these conditions.22 With bipartisan support for the proposed Opioid Workforce Act of 2018, the country is hopeful for an expansion in graduate medical education, by 1000 additional Medicare-supported residency positions to teaching hospitals. This provides a nationally targeted investment in a workforce that is competent in the management of acute and chronic pain. Growth in physiatry must be a part of this targeted investment. Physiatrists are an essential and unique resource in this public health crisis; although most health care providers focus on pain reduction, physiatrists collaborate with patients to work toward improvement of function and quality of life. This deep-rooted approach prioritizes physical modalities and exercise, the importance of alternatives to opioids, plus holistic care with attention to the psychological and social aspects of pain. There is no other field of medicine where providers master the assessment and treatment of both pain and function. It is therefore crucial that any upcoming expansion in graduate medical education, targeted to the opioid crisis, include deliberate growth in physiatric residency positions.
The opioid crisis is complex but driven in large part by the excessive prescription of opioid medication for both acute and chronic pain. Physiatrists are aware of the limitations of opioid treatment for acute pain as well as for chronic pain and disability, wary of the dangers of chronic opioid use, and experts in identifying effective nonopioid strategies for painful conditions. In addition, physiatrists are aware of the danger posed by viewing pain reduction as the primary end point in pain management. Physiatrists have unique experience setting appropriate expectations and incorporating an emphasis on function and quality of life rather than pain reduction in isolation when treating individuals with acute and chronic pain. Physiatrists are facilitators for primary care providers and surgical practices to integrate care for the benefit of patients with pain conditions, improve quality of care, and minimize the harm that is caused by opioid medications. Physiatrists are experts in the treatment of complex pain and disability using intensive rehabilitation strategies. However, these effective nonopioid treatments can be difficult for patients to access because of the burden of medical costs caused by current policies. Furthermore, if pain research does not include an enhanced focus on functional outcomes and if graduate medical education expansions aimed at the opioid crisis do not include a strong physiatric contribution, our nation's ability to address the opioid crisis will be jeopardized. We must support rehabilitation-based nonopioid treatments for acute and chronic pain, nonpharmacologic and nonopioid pain research that measures patient function, and a deliberate expansion in physiatric residency positions to provision the right resources to meet the nation's healthcare needs.
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Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Association of Academic Physiatrists; Opioid Crisis; Pain Medicine; Physiatric Medicine; Position Statement; Graduate Medical Education; Advocacy; Pain Management