Nicholas Giordano is on a mission to understand one of the most common human burdens: pain.
“Pain is such a unique experience, and yet it's universal,” says Giordano, assistant professor in Emory’s Nell Hodgson Woodruff School of Nursing. “Everyone experiences pain, but something that’s a 9 or 10 to you [on a pain scale of 0 to 10] may be different than what it is for me.”
Giordano’s research is aimed at finding better, more personalized ways for health care professionals to help patients manage their pain, with a goal of reducing the use of opioids after surgery.
His research partner, Mara Schenker, an orthopedic trauma surgeon at Grady Memorial Hospital and a professor of orthopedics in the School of Medicine, believes these changes can’t come soon enough.
“I take care of patients at the most painful moments of their lives,” she says. “I realized that I needed some self-education about alternative strategies for pain management that weren't necessarily a pill, which is what I was trained to use for pain management and what likely contributed to the opioid epidemic. I want to help patients in a way that doesn’t always rely on a pill.”
Giordano and Schenker’s research is driven by a recognition that post-trauma pain is a complex psychological response as well as a biological one. Many patients remain on opioids for moderate to severe pain up to six months after their injury and also exhibit a range of other issues, including mental health problems.
Their search for alternative, non-pharmaceutical pain management techniques led them to collaborate with Cammie Rice, an Atlanta-based health activist. Rice founded the nonprofit CWC Alliance in 2018 after her son was introduced to opioids post-surgery, transitioned to heroin and subsequently died. That led Rice to advocate for a new kind of health care support role, called a life care specialist.
People who are life care specialists go through a rigorous training and certification program facilitated by the CWC Alliance in partnership with the Mercer School of Medicine and Grady Memorial Hospital. The training is focused on opioid addiction and treatment, evidence-based pain management techniques and trauma-informed mental wellness skills.
“Physicians and nurses don’t always get comprehensive pain management training in school,” she says. “They don’t always get specialized addiction training. When a patient has an issue, they have to get to the next patient. They don’t have time to do what the life care specialist does.”
CWC Alliance launched the Life Care Specialist program at Grady in 2019.
“Life care specialists teach evidence-based behavioral strategies for pain management,” says Schenker, who serves as chief medical officer for CWC Alliance. “But they’re also educated about the risks of opioids, how to safely use Narcan, and how to educate people on, ‘Hey, what you're taking is an opioid pain medication,’ because oftentimes patients don't even know that.”
Schenker conducted an initial study of the impact of life care specialists at Grady in 2020. That led her to partner with Giordano, and conduct a larger, more rigorous study funded by an award from Emory’s University Research Committee and the CWC Alliance.
“When you have a really strong behavioral intervention, what does it look like compared to the standard of care that everyone else in the world is getting?” Giordano asks. “And that broader standard of care is typically discharge medication and maybe a printed instruction sheet on distraction-based approaches or meditation suggestions.”
The investigation was aimed explicitly at trauma care patients to learn whether personalized pain education and management delivered by life care specialists could help achieve better pain-related outcomes.
Today, life care specialists operate in six Georgia hospitals, serving 1,700 metro Atlanta patients last year in addition to more than 1,500 patients across rural Georgia.
“What's so exciting about this role,” Giordano says, “is having a paraprofessional that understands what a patient experience looks like, being in this vulnerable position without any kind of agency, and can sit with them and help them think through what resources they have available to navigate this painful experience moving forward, while also mitigating their opioid risk.”
Half the patients in the research were coached on mindfulness-based practices and non-medical interventions, while the other half were given normal discharge instructions.
While the experimental group saw measurably better pain outcomes, the improvement wasn’t significant enough to be clinically meaningful.However, these limited but promising results led to the same research team winning funding for a larger study with the National Football League (NFL) and the NFL Players Association on sports medicine injuries. Unlike the first study, this time, the patients will receive life care specialist coaching from day one.
“We’re looking at how we can intervene preoperatively, working with patients to anticipate what their care needs might be after surgery, so that later, when they’re in pain, they can be reminded of the resources and evidence-based practice skills they can draw on postoperatively,” Giordano says.
Schenker and Giordano’s research showing the benefits of life care specialists on patient care has also led to an expansion of services. Data from the URC-supported study helped CWC and Grady Memorial Hospital win additional funding from the Georgia Opioid Settlement to sustain and grow the life care specialist program.
Today, life care specialists, who began by serving patients in orthopedic and trauma, have expanded into additional units including medical-surgical, oncology and hematology, and the pain clinic. The specialists also operate in six Georgia hospitals, including some in isolated rural communities, and CWC recently launched a pilot program in Arkansas. The CWC Alliance says life care specialists served 1,700 metro Atlanta patients last year, in addition to more than 1,500 patients across rural Georgia.
Giordano and Schenker also say the initial URC funding allowed them to broaden their partnerships and cross-disciplinary boundaries in ways that might not have been possible otherwise.
“I was an assistant professor who had just moved to Emory and was trying to launch a research career,” says Giordano. “And Dr. Schenker was willing to work with me as a junior colleague from a completely different department and school to make something really meaningful.”
Schenker adds, “We’re so used to working in silos where we don’t necessarily cross the schools. But this was the right time, right place, right opportunity for us to do truly innovative cross-disciplinary work. I never in a million years could have done this without Nick.”