[groups_non_member group=”premium”]

You probably know someone who has chronic pain, or perhaps you suffer from it yourself. If you think it is a huge health problem, you are right. According to the Institute of Medicine at the National Academy of Sciences, in 2011 over 100 million Americans suffered from chronic pain at a national economic cost of $560-635 billion, exceeding the costs of cardiovascular disease, diabetes and cancer combined—not to mention the incalculable personal cost of suffering and indignity.

You also most probably know, or know of, someone who has died from an unintentional overdose of painkillers and think it is a huge health problem as well. What you may not know is that by the time you finish reading this article, another American will have died from an opioid (painkiller) overdose. According to the Centers for Disease Control and Prevention (CDC), the amount of prescription painkillers dispensed in the US has quadrupled since 1999, despite there being no overall change in the amount of pain that Americans report. This dramatic increase is due to changes in how doctors prescribe opioids.  Furthermore, there is wide variation in painkiller prescribing among the states, which cannot be explained by differences in health issues from state to state.

If you are a subscriber click here to login and read the complete article.  For more information about the JSFB click here  or contact us to learn more about Cornerstone’s research and service offering.

[/groups_non_member]

[groups_member group=”premium”]

You probably know someone who has chronic pain, or perhaps you suffer from it yourself. If you think it is a huge health problem, you are right. According to the Institute of Medicine at the National Academy of Sciences, in 2011 over 100 million Americans suffered from chronic pain at a national economic cost of $560-635 billion, exceeding the costs of cardiovascular disease, diabetes and cancer combined—not to mention the incalculable personal cost of suffering and indignity1.

You also most probably know, or know of, someone who has died from an unintentional overdose of painkillers and think it is a huge health problem as well. What you may not know is that by the time you finish reading this article, another American will have died from an opioid (painkiller) overdose. According to the Centers for Disease Control and Prevention (CDC), the amount of prescription painkillers dispensed in the US has quadrupled since 1999, despite there being no overall change in the amount of pain that Americans report. This dramatic increase is due to changes in how doctors prescribe opioids2.  Furthermore, there is wide variation in painkiller prescribing among the states, which cannot be explained by differences in health issues from state to state.

Cahana_Chart_1

 

Number of Painkiller Prescriptions per 100 people (By US State)

Cahana map

So what is the problem?  Are doctors prescribing too much or not enough? Clearly there are many people with arthritis, back pain, or chronic pain from surgery or an accident who need pain relief, and some of them would prefer to die rather than to go one more day without opioids. But on the other hand, the US consumes 80% of the world’s opioids and 46 people will die today from an accidental overdose.  What should we do? What does science tell us?

Outcome studies are equivocal. Randomized controlled trials evaluating the benefits of prescribed opioids do show short-term pain relief in patients with persistent pain; however, it is difficult to extrapolate these results to all populations and assume a stable hazard-ratio with long-term treatment. Post-eidetic evidence, especially with high-dose opioids, does not show that patients achieve functional recovery and underlines the risk of morbidity such as constipation, accidental falls, insomnia, loss of libido, cognitive decline and addiction3. Nonetheless many prescribers confronted with patients who insist that opioids help them, take the ‘calculated risk’ of continuing to prescribe opioids. This has caused not only confusion within the medical community, but also enmity between those who wish to protect patients by guaranteeing lawful access to pain medication and those who wish to defend society by abuse deterrence.

Reframing the Problem

In order to reverse, not just arrest, this epidemic, society needs to reformulate the problem at hand. Instead of defining it as undertreatment (thus continuing to add new and ‘better drugs’ to the market4) or overtreatment (thus creating policies that unintentionally discourage treating individuals suffering from pain5), we should redefine the problem as the inappropriate treatment of pain. Therefore, we speak not of two epidemics of pain (under- or overtreatment), but rather one syndemic caused by the inappropriate treatment of pain. This syndemic approach means that medical and social solutions should be designed to activate, incentivize and engage affected individuals, families, workplaces and communities to achieve wellness, rather than concentrate on ways to ‘medicalize’ or conversely ‘deprescribe’ the US6.

Treating the Syndemic

Here is where digital opportunity disrupts. Sensors and digital 24/7 tailored services can enable personalized care and interactions with healthcare professionals. A digital ecosystem that constantly monitors how much patients move, how they sleep and what they eat can provide them feedback, as well as allow remote monitoring by healthcare providers and confirm adherence to treatment. The plethora of wearable technology and wireless sensors able to capture biophysical signals and allow real-time alerts can provide actionable information that will promote healthier choices, as a new “Culture of Health” emerges. The Food and Drug Administration recognizes this opportunity, having just recently accepted a new drug application for the first-ever “digital medicine,” a medication tablet containing a sensor to measure treatment-plan adherence and physiologic response. Mapping end-user preferences, life moments, needs and social determinants of health not only creates a ‘dynamic digital phenotype’, but also, more importantly, empowers individuals to live better.

The syndemic of pain is no different than other burdens on Americans’ health such as obesity, diabetes, heart disease or mental illness. Central to making the US healthier is talking less about tests, pills and surgery and more about self-management: how to quit smoking, drink less, eat better, sleep better, exercise more, and manage stress through mindful and meaningful activities. High-cost specialty care has less value, especially as deductibles and co-pays increase, and is rapidly being replaced by digital engagement technologies. Virtual care is here and patients are ready to interact with caregivers and other patients, using secured portals via mobile phones, the Internet, apps and social media. Anytime/anywhere care will become commonplace and the wealth of patient-generated data will reveal the true value of ‘beyond the pill’ treatments, thus driving apt R&D, and will provide the necessary data-driven insights for future market growth and sustainability.

 

1 IOM (Institute of Medicine) report. 2011, “Relieving Pain in America: A blueprint for transforming prevention, care, education and research.” Washington, DC: The National Academies Press.
2 http://www.cdc.gov/drugoverdose/data/index.html accessed Sept 23rd, 2015.

3 Von Korff MR. Long-term use of opioids for complex chronic pain. Best Pract Res Clin Rheumatol. 2013 Oct; 27(5):663-72.

4 In the last decade FDA has approved almost a dozen new, extended release, more potent, abuse deterrent drug formulations. http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm338566.htm. Accessed 9.23.2015

5 The CDC has come out with practice guidelines for opioid prescriptions that many prescribers find hard to follow. http://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-a.pdf. Accessed 9.23.2015

6 This approach was developed and implemented by the Vitality Institute. http://www.thevitalitygroup.com. Accessed 9.23.2015

[/groups_member]

Dr. Alex Cahana is Director of Medical Affairs at the Center for Lawful Access and Abuse Deterrence and theme developer for ARK Investment Management. He has over 15 years of experience in policy and healthcare redesign and serve as a consultant for the Department of Defense and the Veterans Health Administration.