Addressing Chronic Pain in Mississippi: A Population Health Science Approach

Over a decade ago, the National Institutes of Health and Institute of Medicine of Medicine recommended a population based strategy to address the national public health crisis of chronic pain.¹ In this strategy, the traditional definition of chronic pain, pain greater than 3-6 months, would be replaced with a more operationalizable definition to capture how chronic pain interferes with life. High impact chronic pain (HICP) defines chronic pain by whether or not it causes significant amounts of impairment, disability, and health care resource utilization.² Because HICP focuses on pain interference, the burden of chronic pain across different populations and its consequences are more easily measured.² National prevalence studies of HICP have shown the prevalence of high impact pain to be higher in those with lower socioeconomic status and those with public insurance in both non-cancer and cancer populations.^1,3–5 As it relates to the putting HICP pain to use on the national level, HICP, relative to non-HICP, has been shown to predict greater health care costs and utilization, greater opioid use in patients with chronic spinal pain, and to be able to predict outcomes after spine surgery.^3,6–9 In addition, roughly 85% of patients with HICP report the inability to work outside of the home due to pain.³

In 2014, the Mississippi State Department of Health burden of disease report showed that 22% of the population live below the federal poverty level and 20% have less than a high school education.¹⁰ Moreover, it showed that the percentage of Mississippians reporting arthritis exceeded national estimates and activity limiting arthritis disproportionately burdening Mississippians of low socioeconomic status .¹⁰ Consistent with these findings, 2017 state level data estimated the cost of opioid related hospitalizations increased by 17% from 2016 to reach 322 million dollars.¹¹ Moreover, 2017 data showed that Mississippi ranked 8^th in per capita cost of opioid use disorder and opioid related overdose deaths in the United States.¹²

The term HICP was proposed as a tool for pain surveillance to improve population health.² Surveillance of HICP and its consequences can be measured at state and local levels using the brief surveys in appendix A and B, which have been shown to be valid, have a low refusal rate, predict long term pain related outcomes, and reveal health disparities.^{1,4–9,13–15} Surveillance systems, a core function a public health, serve as a beacon for population health.¹⁶ There are opportunities to improve surveillance of chronic pain at state and local levels with the Mississippi State Department of Health and Office of Health Data and Research, which functions to builds data capacity at the state and local levels by conducting population-based health surveys. In addition, it has been shown nationally that hospital systems can combine HICP surveys with data from electronic medical records to monitor pain therapies and outcomes.⁶ With the facts in mind, the following approach should be considered in state and local context to address chronic pain and chronic pain surveillance in Mississippi:

1. Estimate the prevalence of both chronic pain and high impact chronic pain in the diverse healthcare settings in Mississippi at state and local levels (i.e. primary care, post-surgical, pediatric and cancer). Define the determinants of chronic pain and high impact pain across populations in Mississippi.

2. Track and measure how different populations with chronic pain and high impact chronic pain utilize pain treatment resources and other health care resources.

3. Gather insights on the quality of pain care received by populations with chronic pain and identify emerging needs.

4. Quantify the economic impact of healthcare utilization and disability in chronic pain populations.

5. Institute interventions and appropriately allocate resources. Appropriate interventions include changes in policies that target social determinants and health behaviors, improving access to evidenced based pain treatments, educating the health care workforce, and the implementing innovative informatics tools such as telehealth.

6. Evaluate the cost effectiveness of such interventions at the population level.

Prior reports suggest that HICP is associated with factors prevalent in Mississippi: poverty, low education, inadequate insurance, and African American race.^{1,4,5,8,10,14,15} Considering both the economic implications of the disability, health care resource utilization and differential population burden of disabling pain in Mississippi, it is prudent for health care leaders, public health professionals, researchers, and policy makers in Mississippi to collaborate to develop improved pain surveillance and population-based pain research to enhance the care of Mississippians with chronic pain.