PALM BEACH, Fla.—An ad hoc coalition of leading pain specialists and representatives from key clinical and patient advocacy organizations convened in November 2008 to address the growing problem of misuse and abuse of pain medications, and to strengthen support for recognizing chronic pain as a distinct disease state—an important step toward improving the diagnosis and treatment of patients with pain.

The roundtable included representatives from primary care and specialty medicine, nursing, nurse practitioners, and physician assistants, as well as representatives from the American Academy of Pain Medicine, the American Pain Society, the American Chronic Pain Association, National Pain Foundation, the American Pain Foundation, and other leaders in the pain community.

The goals were to review the barriers to diagnosis and treatment of acute and chronic pain in clinical and community settings; increase public awareness of the disparities in pain treatment based on gender, race, ethnicity, and age, and provide recommendations to enable clinicians to overcome these barriers; implement management strategies to provide adequate pain relief for a spectrum of patients, including those who may be at highest risk for medication misuse, abuse, and diversion; and discuss emerging technologies to deter misuse, abuse, and diversion of opioids.

Roundtable participants began by delineating some of the current obstacles to meeting their goals, and then collaborated on possible solutions. One of the major obstacles, they argued, is the inconsistency of guidelines for the diagnosis and treatment of pain, which represent a number of individual organizations and pain societies. Therefore, reorganizing the organizations and societies in the pain community into a single united group could enhance cooperation and eliminate fragmented guidelines and treatment standards. Similarly, the lack of standardized procedures for patient assessments (which should include physical examination and functional evaluation before and during treatment) has led to a lack of outcomes data in pain medicine. Development of protocols for outcomes studies—particularly studies that look at the effects of pain and treatment of pain on function and quality of life—as well as the generation of “best practices” can help overcome these obstacles.

The medical community's focus on global outcomes of treatment, rather than on patient-specific outcomes, is yet another obstacle to optimal treatment for pain. But by having patients actively involved in their management plan, healthcare providers can become more knowledgeable patient advocates with legislators, insurers, and other medical professionals. Because it is not possible to provide complete relief to all patients with pain, education about realistic treatment outcomes is key for both patients and healthcare providers. For example, by becoming active members of their treatment teams, patients may realize improved quality of life despite persistence of a certain level of pain.

Opioids are not appropriate for all patients with pain—for example, those whose pain is mediated through inflammatory pathways, who are more effectively treated with anti-inflammatory drugs. Nor are opioids appropriate for patients who may misuse/abuse/divert these medications. However, this obstacle may be resolved by drugs in development that utilize novel tamper-resistant and abuse-deterrent technologies.  Furthermore, physicians' prescribing of opioids has become limited not only by their abuse potential but also by the increased possibility of litigation and changes in medical insurance and governmental policies.

In the past 10 years, adolescents and young adults have escalated their abuse and non-medical use of opioids. In 2006, 10% of youths aged 12 to 17 were current illicit drug users, with 3% using prescription drugs nonmedically, and nearly 20% of young adults aged 18 to 25 used illicit drugs, with more than 6% using psychotherapeutics nonmedically.  At the same time, many (or even most) parents remain largely unaware that their children may be abusing drugs.

Roundtable participants agreed that many of these obstacles to effective diagnosis and management of pain could be resolved by making pain medicine a primary medical specialty. As a positive first step, they said, a 2-year fellowship or 4-year residency program in pain medicine should be established in the medical curriculum. Training for pain medicine specialists would include all facets of pain management (for example, anesthesiology, physiatry, psychiatry, rehabilitation). The benefits of this expertise in pain medicine could then be extended by incorporating pain management principles into other programs, promoting learning for nurse practitioners, physician assistants, and other allied health professionals.