About 30% of the U.S. population experiences chronic pain, Dr. Williams said. However, “Optimal care is rarely administered in routine care, particularly in rural settings,” he said. Although 75% of the U.S. population lives in urban areas, this still leaves 25% of the population in rural areas, where there are often disparities in pain care.
“Access to trained practitioners is sometimes limited or not found in rural settings. There’s a burden to travel, and there are perceived costs associated with care,” he said.
Additionally, patients in rural areas are more likely to be older, economically challenged, and have overall poorer health, and are less likely to have Medicaid or employer health insurance. At the same time, there are fewer physicians in these areas and fewer still that are trained in behavioral or exercise interventions that are becoming more important in chronic pain treatment, Dr. Williams said.
There is also a trend to view chronic pain not based on the body region where the pain occurs but more as a mechanism that could be placed in one of three categories: peripheral damage or inflammation, such as with rheumatoid arthritis or osteoarthritis; neuropathic, such as lower back pain; and central nonneuropathic noninflammatory pain, such as fibromyalgia, irritable bowel syndrome, or interstitial cystitis. However, this kind of approach is still slowly spreading from tertiary care in urban areas to rural settings, Dr. Williams said.
Because the new approach to pain is slowly changing, inappropriate pain treatment continues, including prescribing opioids or nonsteroidal antiinflammatory drugs for fibromyalgia patients, despite the lack of evidence that those medications will help this patient group, Dr. Williams said.
Treating Fibromyalgia Pain in a Rural Area
Dr. Williams reported on the results of a study he led regarding pain management for patients with fibromyalgia in a rural Midwestern area. Since the ACR meeting, those results have been published in the December issue of Pain.5 Based on the findings that nonpharmacological approaches such as educational programs, exercise, and cognitive behavioral therapy can help fibromyalgia patients, Dr. Williams and fellow researchers worked with a tertiary setting in Sioux Falls, S.D., that has 54 clinics in a rural area spreading over 500 miles. Patients in the study were randomized to receive standard care (n=59) or standard care plus a Web-based intervention (n=59), which provided access to a website called “Living Well with Fibromyalgia.” The website included various evidence-based, user-friendly modules for patients to learn about how to exercise properly, how to use relaxation responses, pleasant activity scheduling, and lifestyle changes. Researchers followed the patients over time and completed their final analysis after a six-month period. Participants were primarily female with an average age of 50, predominantly white, and had a 10-year duration of fibromyalgia.
