Chronic Pain: The Other Public Health Crisis

“We want to make sure that as we deal with the opioid crisis, we keep in mind those Americans who are hurting.”

This statement was made by Senate Health Committee Chairman Senator Lamar Alexander during this week’s Health, Education, Labor & Pensions (HELP) Committee Hearing amidst increasing public discussion of the impact of the opioid crisis on chronic pain. The emotional stories of those suffering from chronic pain and struggling to get treatment due to a crackdown on opioid prescriptions has brought to light two separate public health crises facing the U.S.: opioid misuse and chronic pain.

The SUPPORT for Patients and Communities Act passed in 2018 included funding to expand access to medication-assisted treatment and combat opioid misuse, but controversial opioid prescribing guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in unintended consequences for the 50 million Americans suffering from chronic pain and 20 million experiencing high-impact chronic pain.

Senate HELP Committee Hearing

With a goal of better understanding and treating pain, the Senate HELP Committee Hearing featured testimonials from four leaders in pain management:

  • Cindy Steinberg, National Director of Policy and Advocacy for U.S. Pain Foundation and Policy Council Chair of Massachusetts Pain Initiative
  • Dr. Halena Gazelka, Assistant Professor of Anesthesiology and Perioperative Medicine, Director, Mayo Clinic Inpatient Pain Service and Chair, Mayo Clinic Opioid Stewardship Program
  • Dr. Andrew Coop, Professor and Associate Dean for Academic Affairs at University of Maryland School of Pharmacy
  • Dr. Anuradha Rao-Patel, Lead Medical Director for Blue Cross and Blue Shield of North Carolina

Key topics discussed during the hearing included education on pain management for primary care providers (PCP), the pharmacist’s role in the opioid crisis, promising non-addictive pain medicines, reimbursement policies for alternative therapies and coordinated care, and, of course, the unintended consequences of the CDC guidelines on pain management.

PCP Education on Pain Management
According to the Office of National Drug Control Policy, fewer than 20% of the over one million prescribers licensed to prescribe controlled substances have training on how to prescribe opioids safely, excluding federal prescribers who are required to be trained. As Dr. Gazelka mentioned during the hearing, many patients prescribed opioids chronically received their prescriptions from a PCP who is not trained in pain management and lacks the time and knowledge to discuss alternative therapies or refer to high quality pain care specialists.

Equipping PCPs in urban and rural areas with access to evidence-based treatment guidelines for common pain complaints and connecting them with high quality and in-network advanced pain care providers for complex cases is crucial. As a supplement to these resources, clinical consultation with experts in pain management and medication can increase confidence in prescribing appropriately, which can begin to address the devastating trend of patients being forcibly tapered or dropped by their PCP due to fear of prescribing.

The Pharmacist’s Role
An important message made clear by Dr. Coop during the hearing is that pharmacists are incredibly underutilized as a means to combat the opioid crisis, despite being acknowledged drug experts. To many, the pharmacist’s role is associated with dispensing medication in retail pharmacies, but they can and do play a much larger role in the healthcare ecosystem and their expertise should be leveraged to its full extent.

Incentives should be put in place to include pharmacists in a patient’s core care team, to communicate regularly with physicians and specialists, counsel on appropriate medications, and serve as a trusted advisor to the patient. And with a dearth of pain management specialists, pharmacists should be considered as a way to fill this gap.

Promising Non-Addictive Pain Medicines
Unsurprisingly, medical marijuana was discussed as a potential non-opioid medication. However, a lack of scientific evidence supporting cannabinoids and barriers to studying the Schedule I drug continue to serve as obstacles. Dr. Coop stressed the need for well-designed clinical studies to fully assess the impact and potential drawbacks, which is something we recently explored in more detail.

In addition to medical marijuana and non-opioid medications, a multitude of alternative therapies have been touted as effective pain relievers, but as we discuss below, reimbursement for and access to these treatments remain an issue.

Reimbursement Policies for Alternative Therapies & Coordinated Care
As alternative therapies such as physical therapy, occupational therapy, water therapy,, and more grow in popularity, health plans have taken steps to increase access by removing prior-authorizations, although many critics still say access is difficult. America’s Health Insurance Plans published a statement following the hearing that emphasized progress in evaluating non-opioid care treatments as a first-line option for the treatment of pain, writing “As we move from routinely prescribing opioids for pain, we all have a role to play to ensure patients receive effective pain care. … Both clinicians and health insurance providers together will need to manage the new realities of a comprehensive, integrated, patient-focused pain management approach.”

In addition to knocking down barriers to alternative therapies, the importance of coordinated care incentives was weaved into nearly every witness’ response. Patients suffering from chronic pain are more likely to experience mental a health disorder, meaning treatment should address the patient’s whole health. Dr. Gazelka referred to the pain clinic model from 30 years ago, which included a physician, psychologist, and restorative therapist, and encouraged returning to this model.

Unintended Consequences of CDC Guidelines on Opioid Prescribing
As Dr. Gazelka mentioned during the hearing, many in the pain management space believe restricting opioids before alternatives were made more accessible has led to significant unintended consequences. Specifically, this restriction refers to the CDC opioid prescribing guidelines designed with the goal of educating primary care providers without extensive pain management training on best practices for opioid prescribing. However, a misunderstanding of the CDC’s intent has contributed to potentially harmful legislative regulations around opioid prescribing for patients in pain. Physicians and physician advocates such as the American Medical Association have made statements on the misapplication of the guidelines, and our own team heard this frustration first hand from practitioners at PAINWeek last September.

Emphasizing the complexity of pain, Dr. Gazelka and Steinberg both shared scenarios in which positive patient outcomes were achieved through care that falls outside the recommended CDC guidelines. The stories highlighted the most important takeaways from the hearing: No two people experience pain in the same way, and we must keep the importance of personalized, patient-centered care in mind as new efforts are implemented to combat the opioid crisis.

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