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    News of medicine.

Finding Alternatives to Opioids



Pressures on primary care doctors to move away from opioid pain management are increasing, but practitioners need practical, evidence-based information on how to employ multidisciplinary pain care successfully in everyday clinical practice.

A senior investigator for Kaiser Permanente, speaking at the American Pain Society Annual Scientific Conference, believes wider use of practical clinical trials and more emphasis on patient self-management are key solutions for achieving wider use of multidisciplinary pain care to improve patient function and help lower use and misuse of opioids.

While the national death toll from opioid overdoses is staggering, Lynn DeBar, PhD, senior investigator, Kaiser Permanente Center for Health Research said that a small minority of pain patients are represented in the mortality data.

"Given the justified apprehensions of primary care doctors to continue prescribing opioids, the central question focuses on what can we do in primary care to help improve function for pain patients," said DeBar.

DeBar said the benefits of multidisciplinary pain care, which employs non-pharmacologic treatments, have been well documented in peer-reviewed studies but it still is not widely available due largely to inadequate insurance coverage.

"Medicare and other health insurance providers need value-based care metrics and outcomes, and more studies are needed to help implement evidence-based multimodal pain care with attention to feasibility and sustainability in everyday clinical practice," DeBar explained.

Widespread gaps in evidence-based knowledge about pain management underscore the need to conduct practical clinical trials designed to meet the needs of clinicians and answer their questions. Such trials are of increasing interest to the National Institutes of Health who are ramping up efforts to support pragmatic trial initiatives.

"Practical clinical trials can bridge the gap between research and clinical care," said DeBar. "Traditional randomized clinical trials are slow and expensive, and results often cannot be implemented easily in clinical practice. Findings can be difficult to translate into the real world because treatments are given to carefully selected populations in ideal conditions."

DeBar said practical clinical trials are designed to improve practice and policy and take place in settings where routine medical care occurs. They seek answers to real-world clinical questions and are designed to test what will work in everyday care. Also, practical clinical trials study diverse populations using broadly inclusive eligibility criteria.

The NIH Health Care Systems Research Collaboratory, is spearheading execution of pragmatic clinical trials in pain management by partnering with health systems and physician groups. "Engaging health systems, provider and patients as partners in pragmatic research accelerates realistic integration of research, policy and practice," said DeBar.

She reported that Kaiser Permanente is organizing a practical clinical trial in pain management involving 851 patients in the Portland, Ore. area. DeBar also spoke about the benefits of adopting alternative treatment approaches, such as virtual reality and patient-to-patient reinforcement methods.

"Remote interventions with cognitive behavioral therapies are proving effective and so are new smart phone apps that allow patients to transmit real-time information about their pain," said DeBar.

"Also, more attention should be given to patient-driven models of support, similar to programs like Weight Watchers, which empower patients to take more active roles in managing their care."

Materials provided by American Pain Society.


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