NATIONAL HARBOR, Md. — Creating more evidence-based, patient-centered, multidisciplinary models of pain management and better utilizing self care to improve patient function was the focus of the opening keynote at the American Academy of Pain Management 2015 meeting.
Doing so will require a creating a “cultural transformation,” according to speaker Wayne B. Jonas, MD, a professor in the department of family medicine at both Georgetown University School of Medicine in Washington, DC, and the Uniformed Services University of Health Sciences at the University of Maryland in Bethesda.
More than 100 million Americans live with chronic pain, costing the nation between $560 to $635 billion annually, and US military personnel are disproportionately affected — as many as 44% of soldiers report chronic pain and as many as 15% regularly use opioids.
In response to the growing number of service members using opioids for chronic pain, both the US Department of Defense Pain Management Task Force and the Institute of Medicine (IOM) have called for more comprehensive pain management plans, better tools and infrastructure to support research advancements in pain management, and more cultural integration of pain awareness, education, and proactive interventions.
Although medications are the primary treatments for pain and are mostly appropriate and required, current approaches to pain management often do not address the whole person, according to Jonas. Chronic pain is a complex condition that involves physical, emotional, spiritual, and mental processes.
Approaching pain management from a framework that focuses on salutogenesis, or the process of recovering, repairing, restoring, and retaining health and wholeness, rather than from a framework of pathogenesis, the mechanism by which a disease is caused, may better address the various facets patients with chronic pain experience.
“It is important that pain management specialists create a culture that makes healing as important as curing,” said Dr. Jonas, who is also the president and chief operating officer of the Samueli Institute, a nonprofit research organization in Alexandria, Virginia, that is dedicated to investigating the safety, effectiveness, and integration of healing practices.
In order to create optimal healing environments, healthcare providers must focus on surrounding the patient with elements that facilitate this healing process. These include internal elements (personal wholeness and healing intention), interpersonal components (healing relationships and organizations), behavioral considerations (healthy lifestyle and integrative care), and external factors (healing spaces and ecological resilience).
Compiling a HOPE Note
A tool Dr. Jonas called a “HOPE note” may be able to help pain management providers incorporate each of these four elements into bedside practice during patient assessment.
“The SOAP note is a wonderful way to deliver curative medicine,” said Dr. Jonas. “It got me thinking ‘How can we create a process that’s as easy as a SOAP note for delivering salutogenic approaches at the bedside?’”
Every medical student learns how to perform a patient assessment using the SOAP note acronym, which requires a subjective description of the health problem, an objective observation of pathology, assessment via diagnosis of the disease or illness, and plan for treatment, and many electronic health records are structured using this as a model.
However in the HOPE note, Jonas explained that the subjective, objective, assessment, and plan elements are replaced with the four components necessary for an optimal healing environment:
Internal. The first step is asking patients to define their intention by stating their personal goals for treatment. The goal should be specific, but can be as wide ranging as climbing stairs or seeing a grandchild. Ask patients to rate their health on a scale of one to 10 and to define their expectation for improvement. Find out what brings them joy and purpose in life.
Interpersonal. Next, inquire about patients’ relationships and hobbies. Ask patients to describe themselves, their traumas, their friends, and any groups or clubs to which they belong.
Behavioral. Ask lifestyle questions about tobacco, alcohol, drug, and medication use. Inquire about diet, exercise, sleep, and stressors. Assess use if complementary and alternative medicines such as supplements and herbs, and if patients are seeing any other practitioners to treat their pain.
External. Assess the patients’ home and work environments and the presence of elements such as light, noise, nature, clutter, guns, and if it is safe.
“We have found that yoga, tai chi, and music therapy have reasonable adequate evidence for implementation in pain management practice, but many patients still do not have access to these services,” said Dr. Jonas. “We need more than the evidence. We need to figure out how to deliver these types of therapies in practice both on an individual basis and at the organizational level.”
Going beyond the bedside, Dr. Jonas called on healthcare systems to create learning communities to translate these ideas in a way that promotes collective meaning. He is currently involved in organizing and managing a chronic pain breakthrough collaborative that bring together healthcare providers working to create reliable operations and processes to support better patient-centered pain management and sustainable business models for delivering integrated care.
Dr. Jonas is currently seeking participants for a second collaborative focused on palliative care and home hospice planned for April 2016.
- Jonas WB. How Healing Happens in Pain: The Role of Self-Care and Integrative Medicine. 2015; Presented at: AAPM 2015; Sept. 17-20, 2015; National Harbor, Maryland.