If you haven’t experienced chronic pain, chances are somebody you know has. In fact, over 100 million American adults suffer from chronic pain, defined as pain that lasts longer than six months. It’s a major cause of missed work, the most common cause of long-term disability, and is complex and unique to each person.
Fortunately, a diverse array of University of Maryland, Baltimore (UMB) researchers is confronting the challenge head-on with an interdisciplinary approach to better understand, treat, and modify the impact of chronic pain. UMB has been the epicenter of robust chronic pain research for many years. In 2014, the University of Maryland Center to Advance Chronic Pain Research (CACPR) was established to build on decades of multidisciplinary pain research and expand innovative collaborations across the University.
“It’s really quite remarkable,” said Joel D. Greenspan, PhD, co-director of CACPR and professor and chair, School of Dentistry Department of Neural and Pain Sciences. “There’s really no place like this. Despite pain clinics of different sorts around the world, no one has the breadth of talent in the topical areas that we have.”
On Oct. 16, Greenspan and other top-tier pain researchers and medical professionals associated with CACPR gathered at the Padonia Park Club in Cockeysville, Md., for a community discussion on chronic pain. In addition to Greenspan, panelists included Thelma Wright, MD, JD, assistant professor of anesthesiology, School of Medicine; John Cagle, MSW, PhD, assistant professor, School of Social Work; and Diane Hoffmann, JD, MS, director, Law and Health Care Program, Carey School of Law.
“As many of you may be aware, for the past decade or so chronic pain has grown to almost epidemic proportions,” said Cynthia Renn, PhD, RN, FAAN, associate professor at the School of Nursing who served as moderator of the forum, which drew an audience of clinicians as well as chronic pain patients and their caregivers.
Wright, director of the University of Maryland Pain Management Center, explained the multidisciplinary treatment approach of the center. “We treat every condition from headache pain to foot pain,” she said, with a protocol that does not necessarily include opioids. Treatment can include anticonvulsants, muscle relaxers, anti-inflammatories, steroid injections, and acupuncture. “We’ve got a lot of stuff in our toolbox,” she told the crowd, including advanced therapy options such as a spinal cord stimulator that involves putting electrical leads into the epidural space to dull pain.
Treatment at the pain center also includes visits with a pain psychologist. “We know that patients who have chronic pain have a history or comorbid conditions such as depression and anxiety,” Wright explained. “The pain psychologists are there to help patients cope with the pain through relaxation training and biofeedback.”
Cagle is familiar with the anxiety and depression that can come with chronic pain. He also knows knowledge is power when it comes to treatment.
As a hospice social worker, he focused on addressing the pain that can occur at the end of life. During his talk, “Overcoming Barriers to Pain Management at the End of Life,” Cagle addressed the myths patients and families entering hospice have about pain medication, which are often concerns about addiction, developing an intolerance, and the fear of overdose.
Cagle’s research shows when patients were provided evidence-based information to address misperceptions about pain medicines, after about two weeks they reduced their ratings on a pain scale. “We found a reduction of 1½ to be clinically meaningful. We were surprised by that,” he said. “That’s been giving us momentum to move forward with the next steps in this project,” which is examining how the opioid epidemic is creating policy-related barriers for hospice proprietors.
The pendulum in pain medication policy has swung from one extreme to the other, according to Hoffmann. When she began scholarly research about pain medication regulation in the late 1990s, there was concern about the undertreatment of chronic pain. Fast forward 20 years, and over-prescription of the powerful opioid drugs became a crisis.
“But then around three years ago the pendulum started swinging the other way,” Hoffmann noted. The strict enforcement of Centers for Disease Control and Prevention (CDC) guidelines published in 2016 resulted in doctors abruptly tapering chronic pain patients off opioids. This left some patients in excruciating pain, Hoffmann explained, leading some to end their lives.
Hoffmann’s advocacy for pain patients along with collaboration with other legal and pain experts resulted in a letter drafted to the head of the Department of Health and Human Services (HHS) suggesting more compassionate tapering of pain patients from their opioids. The CDC publicly acknowledged the rules were being misapplied in an article in The New England Journal of Medicine.
Hoffmann was happy to report to the audience that in mid-October HHS came out with a policy instructing doctors on how to successfully taper patients off of opioids. “I think it is a wonderful step forward because physicians are taught how to prescribe medication but not how to take patients off of it.” She is hopeful that these steps will correct some of the policy imbalance and that “patients who haven’t been able to get their medicines will finally get the care they need.”
The forum ended with a robust question-and-answer session during which clinicians and patients asked panelists pointed questions about pain treatment.
“I hope people heard some useful information and are inspired to come to the University of Maryland to check out some of the options that are available,” Renn concluded.