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According to a study conducted by the Centers for Disease Control and Prevention (CDC) in 2016, an estimated 20.4% (50 million) of adults had chronic pain in the U.S. September is Pain Awareness Month, a time to raise public awareness about chronic pain and pain management.
The American Association of Nurse Practitioners® (AANP) spoke with AANP Fellow and chronic pain expert, Brett B. Snodgrass, FNP-C, CPE, ACHPN, FAANP, about providing pain management to rural communities, communicating the goals and risks of pain care regimens to patients and illuminating the role nurse practitioners (NPs) play in improving chronic pain outcomes.
Brett B. Snodgrass: I’ve been a nurse for 25 years and an NP for 15 years. I had no plans to become an NP — I was very content working as a registered nurse (RN) working with cancer patients. When one of the physicians I worked with decided to open up a new practice, I saw the need for an NP there and decided to make the transition to fill that role myself.
It was a very abrupt decision. I saw a need and just wanted to fill it, all while gaining more autonomy and the ability to do more with an advanced degree. Although there were obstacles, my colleagues greatly supported me and allowed me to fall in love with being a NP. You have to do this for the right reasons: because you want to be an NP, because you want to be a part of change, because you want to take care of patients.
Snodgrass: I’ve been in the chronic pain world the entire time I’ve been an RN and an NP. I’ve always had my foot in some type of pain management, whether I’m dealing with end-of-life care or pain in the acute care or oncology settings.
The physician who I started a practice with also had a role in palliative medicine. We started the first palliative program in the Memphis area, and we always had patients within our practice who had some kind of a pain diagnosis. Early on, our rural practice was divided evenly between a regular family practice and a palliative care and pain management practice. Our patients did not have access to pain management offices in our area, and so we filled that need.
For a number of years, I worked in chronic pain, and I actually opened and ran a couple of chronic pain practices in my area. As I mentioned before, there was a major access issue — we did not have many chronic pain practices where patients could be seen for their chronic pain and be treated appropriately. We hear a lot about pill mills and overprescribing, but when you look at the whole picture, there’s a lot of undertreatment of pain and lack of access to care.
Snodgrass: The opioid epidemic has its roots in the ‘90s. Back then, pain was declared the fifth vital sign and became tied to patient satisfaction scores and provider reviews. Patients at that time would be asked if their pain was treated — essentially 100% removed — which providers frequently cannot do. As providers were repeatedly penalized for this, they began prescribing opioids to eliminate their patients’ pain.
In the early 2010s, the conversation began around the overprescribing and use of opioids. Data showed a rise in both opioid prescriptions and overdose deaths, yet pain was not much more controlled than it ever was. Providers began cutting off opioid prescribing or walking away from treating pain altogether. While in recent years we’ve seen a decline in opioid prescriptions, we are still seeing a steady and slow increase in overdose deaths. This data helped reveal the mental health epidemic that has been going untreated and fueling opioid use across the country.
Now, we understand that we have to prescribe opioids in appropriate populations — and to the appropriate people. Who are those people, how do we identify them and how do we appropriately treat pain — perhaps not with opioids, but with other therapies to care for our patients in a safe and proper way? That’s why I’ve created these educational programs.
Snodgrass: NPs do two things exceptionally well — we are equipped to educate and trained to take care of the whole person. It’s about individualizing treatment for the patient and making certain the patient understands what these treatments can really do.
If you talk to a patient early on about their pain treatment, they’ll tell you they want their pain reduced to zero. But from a provider’s perspective, the best outcome for chronic pain patients is probably a 30%-50% reduction of pain. So, it’s really about educating patients about what to expect from their pain regimen and setting those expectations very early. We are focused on providing functionality. The goal isn’t getting your pain score to a zero, but about what you can do with your pain regimen that you couldn’t do before.
Snodgrass: Wherever patients have a limited access to health care providers, there are also restrictions placed on NPs looking to treat them. Tennessee is made up of largely rural areas. While we don’t see many people knocking down doors to get into these areas and start practices there, NPs are prepared and eager to do just that — yet, the cost of physician oversight that’s needed for NPs to just open their doors in these rural communities is so high that it makes it nearly impossible. Removing the practice and oversight barriers for NPs can truly transform patient outcomes in these rural areas.
Snodgrass: I think it’s multifaceted. It has been encouraging to see an increasing effort to integrate more pain management education in advance practice registered nurse, physician, physician assistant and pharmacy graduate programs. More needs to be done for providers in primary care, like family practice, where patients first appear with their pain concerns. We have to further support practitioners from all disciplines, so they are offering the right modalities and keeping their patients safe.
Secondly, I think we need to work with insurance companies and payers to get other multimodal pain therapies covered. Often, health care providers can’t get patients’ massages, injections and other therapies readily covered by their insurance. Sometimes opioids are the only solution because they are the only treatment covered by insurance, so we need to work to provide our patients with better options.
Do you want to further your knowledge of pain management and pain care? Help increase the quality of life for patients with chronic pain by completing continuing education (CE) activities in the AANP CE Center. Browse courses in the pain category, improve outcomes in primary care for patients with axial spondyloarthritis and learn the essentials of pain management while earning valuable CE credit.