Author, Needless Suffering; How Society Fails Those with Chronic Pain
The Comprehensive Addiction and Recovery Act (CARA) was passed by the US Congress in 2016. The first provision of this law was to create what became known as the Pain Management, Best Practices Interagency Task Force (PMBPITF). While it may seem a bit odd that a broad look at pain management would be provision of a law looking at the issue of addiction in America, it is actually a very good first step in helping to create a public policy balance between the issues of chronic pain, which affects over 50 million Americans, and opioid abuse disorder, which affects fewer than 2 million. Both problems are pervasive, yet poorly managed in our culture. The following is a commentary on the Draft Report released by the Task Force.
The popular narrative is that the explosion in opioid prescribing and opioid abuse over the past twenty years is due to excess prescribing from doctors, excess expectations of pain relief from those in pain, and greed from the pharmaceutical industry. While this narrative is not entirely false, it greatly over-simplifies a complex social situation. Beginning with the passing of the Harrison Act in 1914, chronic pain became viewed as a character flaw and addiction as a crime. To seek relief, those in pain frequently had to take to the streets to obtain medications and other care which was not forth-coming from the medical profession, risking a criminal act and the ramifications that go with that. By the mid-1980’s, this mind-set began to change for end of life care and by the late 1980’s, the same could be said of both acute and chronic pain. Pain could no longer viewed in the health care industry as a character flaw and both the legal and health care industries issued statements that those in pain should not have to suffer.
The problem was a lack of effective therapies beyond opioids to meet these expectations. Even if there were effective alternatives, frequently there was a lack of access to these. This lack of access led to an explosion of opioid prescribing in the late 1990’s. The most feared consequence of opioid use/abuse is addiction. While the risk of de novo addiction to opioids has been and remains greatly exaggerated, opioid abuse/mis-use and diversion became increasing problems, as has been unintended overdose deaths due to opioid alone or, more commonly, multiple agents simultaneously, both prescribed and un-prescribed. A lack of health provider education about pain management, in general and opioid prescribing, in particular, aggravated the problem even though most states, by 2000 had passed opioid prescribing rules which had first been created by the Federation of State Medical Boards in 1998 (revised in 2004, 2013, and 2017).
The call for alternative therapies for pain management including multi-modal care began early in this process, but first became public policy with the passing of the Pain Care Policy Act in 2009. This act led directly to the 2011 Institute of Medicine (IOM) report entitled Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, which then led to the National Pain Strategy (NPS) released in March, 2016. Similar policy statements came from the CDC with the March 2016 release of the CDC Guidelines for Prescribing Opioids for Chronic Pain, and from the National Academy of Sciences, Engineering and Medicine report Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use, also in 2016. The Consumer Pain Advocacy Task Force (CPATF) also released their “core principles” around this time, one of which states: “effective chronic pain care requires access to a wide range of treatment options, including biomedical, behavioral health, and complementary medicine.”
What I find most concerning from my experience speaking to health care providers and legislators all over the country is how few individuals know these efforts exist.
Overview of the Interagency Pain Management Best Practices Draft:
With this as a backdrop, the PMBPITF draft report was released in early 2019 with a window for public comment until April 1, 2019, and the final report is to be released in May, 2019. All the reports referred to above, including the PMBPITF draft, make a statement similar to the FSMB report of 2013:
“There is a significant body of evidence suggesting that many Americans suffer from chronic pain and much of that pain is inadequately or ineffectively treated… Undertreatment of pain is recognized as a serious public health problem that compromises functional status of and quality of life. A myriad of…factors-including inconsistencies and restrictions in state pain policies – can either facilitate or impede the willingness of physicians to manage patients with pain.”
The purpose of the PMBPITF draft is to take a comprehensive, though not thorough, look at how we manage both acute and chronic pain in America, and to “determine whether gaps in or inconsistencies between best practices…exist and to propose updates and recommendations to those practices.” While that is the mission, that is not really what the report accomplishes. In reality, the report does not create best practice. Rather, it lists a series of modalities categorized by:
- Restorative movement therapies
- Interventional procedures
- Complementary and integrative health
- Behavioral health/psychological therapies
It states that the list of modalities reviewed is, by design, not exhaustive, given the innumerable modalities present, nor is evidence for each modality listed exhaustive. Gaps in understanding of each modality and each category are listed as are recommendations to bridge those gaps.
It should be stated at this time that the report attempts to define “best practices” based on evidence. It is generally recognized in pain management that the evidence base for nearly all modalities and practices is limited. Most modalities help someone, none help everyone, and most patients require multi-modal therapy, all of which makes scientific study more challenging. The unique set of circumstances that each patient presents further complicates the use of evidence based medicine in this setting. Therefore, the best that can be done is develop best practices which are adaptable to individual settings and over time as evidence accumulates. The Draft Report, to its credit, acknowledges these limitations.
Unlike the CDC report which is broadly criticized for its exclusivity, the authors of the Task Force Draft Report include a broad array of stakeholders – including a pain patient. This does more to ensure all voices are heard.
The critical and most important feature of the Draft Report is its overall focus on increasing access to all pain management techniques for all those in pain, no matter their social station. The report acknowledges that opioids have a role in pain management, but by creating more options, including multi-modal care, the overall need for opioids will diminish.
The strength of the report comes with what it does emphasize.
- Balance between the needs of those who suffer from pain, addiction, and mental health disorders
- The need for individualized, comprehensive, integrative, multi-disciplinary, bio-psycho-social care
- The need to address and minimize disparities in pain care
- The need to de-stigmatize those who suffer from chronic pain through public and professional education.
- The need to improve access to care in all the categories mentioned above.
- The need to increase the workforce of pain management providers across all disciplines
- The need to increase innovative strategies to improve access to pain management services
- The need to increase research in pain medicine techniques
- The needs of “special populations,” forcing the reader to look at the complexity of pain from the young to the old, male/female, rural/urban, veterans, acute/chronic/end of life, etc.
- The benefits/risks of opioids and public policy are discussed in two separate sections emphasizing the unique aspects of this set of pharmaceuticals. The report discusses how public polices generated from the CDC guidelines have harmed many patients including death due to suicide, and recommends changes in that guideline to reflect recent evidence. Because of the carnage created by public policies inappropriately modeled after the CDC guidelines these are critical and important statements.
- The section on behavioral health/psychological therapies is unique, comprehensive, and important.
- One cannot overstate the importance of the recommendations on public and professional education.
The weaknesses of the report are:
- What this task force has started is unique and extremely important. However, the statute states specifically that “the task force under this section shall sunset after 3 years.” What happens then? This is important because too few are aware this effort exists. Similarly, the National Pain Strategy was released by HHS the day after the CDC guidelines. Very few have ever heard of the NPS including many in the pain care community. The NPS currently exists in name only and that is a problem. The PMBPITF has adopted many themes from the NPS, in effect keeping it alive. However, there needs to be assurance this effort will maintained in some format. This report cannot be an end, but, rather, a start of a much broader, more constructive social dialogue.
- Related, this task force has no rulemaking authority.
- This report does not really define best practice. In an area of limited evidence, that is a challenge, especially when the consensus is that multi-modal care is needed. This is an issue because increased access is dependent on insurance coverage. Insurers want evidence. While it is quite true that insurers cover many therapies that have no clear evidence of cost/benefit, they do require evidence to justify psychological, behavioral, complementary, and inter-disciplinary therapies. While this may not be fair, it is real.
- Similarly, many potentially effective therapies are not considered.
- The literature review of many modalities is not exhaustive. That is most likely beyond the capabilities and time frame of this task force.
- The section on interventional therapies grossly over-estimates their cost-effectiveness.
- The section on complementary therapies could be more inclusive
- Grieving is an important part of adaptation to persistent pain. Supportive counseling for patients and family is critical, but often neglected. This should be included in the section on behavioral health/psychological interventions.
- The very important role of support groups in helping those in pain adapt to the bio-psycho-social challenges they face is both cost-effective and critical. This is not mentioned in the report and should also be included in the section on behavioral health/psychological interventions.
- While many important recommendations are made, there is no suggestion on how these are to be followed up on. Again, using the NPS as an example, change only happens with perseverance. There needs to be strategy to make sure this happens.
- One of the major problems with disability care in general, and pain management in particular, is a fragmented health care system lacking in continuity which over-rewards those who piecemeal and proceduralize and under-rewards those who manage complex problems. It is critical that those who manage pain care be empowered, and the report does not discuss this.
- Increasing man-power is a critical recommendation. However, there is no clear recommendation on how to make this happen. Pain management is a challenging field and there needs to be incentives to encourage providers to go into it. Assuming a fixed economic health care pie, the only way this will happen is to re-distribute money from those who proceduralize care to those who manage care. In addition to improving remuneration for those who manage pain, addiction, disability, and mental health problems, those willing to go into those fields should receive educational and practice set-up subsidies. Solutions of this sort are not addressed in the report
- Perhaps the most striking omission of the report is there is no mention of medical cannabis. While the use of medical cannabis is against federal policy, over 80% of Americans support its use. Thirty-three states and the District of Columbia have legalized medical cannabis. Over sixty percent of those who use legal medical cannabis use it to treat pain. There are studies which have suggested that medical cannabis use is opioid sparing and that the rate of opioid related deaths have declined in states where medical cannabis is legal. While evidence for medical cannabis remains limited, primarily due to legal and bureaucratic obstacles to proper study, this is a very important medical and social issue and a statement about the current state of scientific knowledge, gaps in knowledge, and recommendations for further study should have been included.
The PMBPITF draft and report to follow are critical to the success of improving how we manage pain in America. It is nearly impossible for a report of this type to be fully comprehensive. The report has been built on the backs of the previous reports referred to. Unlike several of those reports, this effort cannot cease when this task force “sunsets,” and it deserves our universal attention and support. PLEASE take time to review it and offer commentary. The following are ways to do this:
- Submit through the Federal eRulemaking Portal at http://www.regulations.gov, Docket Number: HHS-OS-2018-0027 (If Regulations.gov is inoperable, as a secondary option please submit your comments to email noted below.)
- Email to: firstname.lastname@example.org (Secondary method)
- Mail written comments to:
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Health
200 Independence Avenue, S.W., Room 736E,
Attn: Alicia Richmond Scott, Task Force Designated Federal Officer
Washington, DC 20201