• Referred pain spreads beyond the initial injury site and can have both nociceptive and neuropathic features. 14 • Chronic pain may be primarily nociceptive or neuropathic, or have mixed nociceptive- neuropathic characteristics. New Diagnostic Categories for Chronic Pain Accurately diagnosing a pain condition can be challenging, particularly when the etiology or pathophysiology of the pain is not clearly understood. To systematically gather together all relevant codes for the management of chronic pain, new diagnostic categories in the International Statistical Classification of Diseases and Related Health Problems (ICD-11) take effect in January 2022. 24 These diagnostic categories are intended to assist HCPs in reaching an accurate diagnosis to better create an optimal treatment plan. Per ICD-11, chronic pain is considered primary when pain has persisted for more than three months, is associated with significant emotional distress and/or functional disability, and is not better accounted for by another condition. Thus, in chronic primary pain, the pain is the chief complaint and disease in itself. A diagnosis of somatic symptom disorder, is not made on the basis of unexplained pain alone but requires positive psychiatric criteria. The six subgroups of chronic primary pain are: 24 • Chronic primary pain • Chronic widespread pain (e.g., fibromyalgia) • Chronic primary visceral pain (e.g., irritable bowel syndrome) • Chronic primary musculoskeletal pain (e.g., nonspecific low-back pain) • Chronic primary headache or orofacial pain (e.g., migraine, tension-type headache, trigeminal autonomic cephalalgias) • Chronic regional pain syndrome Chronic pain is secondary when it may, at least initially, be a symptom of an underlying disease. A diagnosis may be made independent of biological or psychological contributors, unless another diagnosis better fits the symptoms. The six subgroups of chronic secondary pain are: • Chronic posttraumatic and postsurgical pain • Chronic secondary headache and orofacial pain • Chronic secondary musculoskeletal pain Chronic neuropathic pain is further subdivided by whether its origin is peripheral or central. 23 Peripheral neuropathic pain is caused by a lesion or disease of the peripheral somatosensory nervous and includes: 23 • Trigeminal neuralgia is an orofacial pain condition of the trigeminal nerve with shooting, stabbing, or electric-shock-like pain that starts and ceases abruptly, and is triggered by innocuous stimuli. • Chronic cancer-related pain • Chronic neuropathic pain • Chronic secondary visceral pain
• Chronic neuropathic pain after peripheral nerve injury is caused by a peripheral nerve lesion with history of nerve trauma, pain onset in temporal relation to the trauma, and pain distribution within the innervation territory. • Painful polyneuropathy is caused by metabolic, autoimmune, familial, or infectious diseases, exposure to environmental or occupational toxins, or treatment with a neurotoxic drug (as in cancer treatment), or can be of unknown etiology. • Postherpetic neuralgia is pain persisting for more than three months after the onset or healing of herpes zoster. • Painful radiculopathy stems from a lesion or disease involving the cervical, thoracic, lumbar spine, or sacral nerve roots, commonly caused by degenerative spinal changes but also by numerous other injuries, infections, surgeries, procedures, or diseases. • Other, not covered by above codes, includes carpal tunnel syndrome and disorders for which information is still insufficient to assign a precise diagnosis. Central neuropathic pain is caused by a lesion or disease of the central somatosensory nervous system, and the pain may be spontaneous or evoked. 23 Central neuropathic pain conditions include: 23 • Chronic central neuropathic pain associated with spinal cord injury • Chronic central neuropathic pain associated with brain injury • Chronic central post-stroke pain • Chronic central neuropathic pain caused by MS • Other, specified and unspecified Conditions may be referenced under more than one category as with chronic painful chemotherapy- induced polyneuropathy, classed as cancer-related pain (by etiology) and also as neuropathic pain (by nature). Although it is clinically useful to speak of chronic pain, it is important to remember that pain is a dynamic experience whose onset, maintenance, and exacerbation is not confined to set temporal categories. 25 Thus, patients who experience significant pain that lasts beyond typical healing periods or the three-month diagnostic period for chronic pain may improve with conservative measures. Conversely, some types of neuropathic pain or sudden onset pain from injury or disease does not require three months before treating the condition as chronic as the pain is likely to persist or recur indefinitely. 23 Because pain can be both a symptom and a disease, an accurate diagnosis is vital to treating the biologic source of pain when it is known and to expediting timely management of pain of uncertain origin. 25 All subtypes of chronic pain should be understood to have multiple biological, psychological, and social factors that contribute to the individual’s pain experience, in keeping with the biopsychosocial framework.
Barriers to Effective Pain Care
The multimodal, multidisciplinary treatment approach is recognized as optimal for pain care; nevertheless, barriers to accessing this type of care for patients are numerous and entrenched in the health-care delivery system. It should be fully recognized that HCPs are asked to provide optimal pain care and lessen the risks from opioids in an environment that frequently provides inadequate support for practitioners and scant access for patients. A task force of health care associations convened by the American Medical Association to study and make recommendations to improve patient pain care described evidence-based care as “ensuring patients have access to the right treatment at the right time without administrative barriers or delay.” 26 Insurance barriers to providing optimal patient care are present in the policies of public and private payers and pharmacy chains as well as pharmacy benefits managers. These barriers include delays and denials from prior authorization, step therapy, treatment quantity limits, high cost-sharing, coverage limits and restrictive access for non- opioid and nonpharmacologic treatments for pain, and strict opioid limits enforced without regard to individual patient need. 26 Barriers to the provision of nonpharmacologic therapies in particular include coverage that is absent or inadequate, unreceptive attitudes of HCPs and patients, and shortages of pain and behavioral health care specialists. 27 An Inter-agency Task Force convened by the Department of Health and Human Services (HHS) to recommend best practices in pain care proposed several ways of addressing gaps: 1 • Create clinical practice guidelines to better incorporate evidence-based complementary and integrative therapies into practice. • Improve insurance coverage and payment for different modalities on the basis of the best practices identified in new guidelines. • Improve coverage and payment for multidisciplinary team care coordination. • Expand access to treatment and geographical coverage via the use of telemedicine and other technological delivery methods for psychological and behavioral health interventions. • Increase the number and training of qualified practitioners in behavioral health and other evidence-based complementary and integrative disciplines. • Provide better education as well as time and financial support for primary care practitioners who give patients the sole available pain care in many parts of the country.
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