Federal Task Force Highlights Ways to Limit Opioid Exposure

Kerry Dooley Young

December 31, 2018

A federal task force may propose a closer look at how insurers' policies deny Americans ways to manage their acute and chronic pain without facing the risk for opioid addiction.

In a draft report released last week, the Pain Management Best Practices Inter-Agency Task Force also stressed the need for changes in the treatment of people already addicted to narcotics, including a call for efforts to address the stigma involved with substance abuse. The Department of Health and Human Services (HHS) told Medscape Medical News that it will accept comments on the draft report through April 1.

The draft report urges "consistent and timely insurance coverage" for interventional procedures, including targeted injections, early in the course of pain treatment. The task force also called for the establishment of criteria-based guidelines for properly credentialing physicians who are appropriately trained using interventional techniques to help manage patients with chronic pain.

The draft report also suggests establishing credentialing criteria that establishes minimum requirements for training physicians in interventional pain management, seeking to bolster use of this approach.

"Unfortunately, pain physician specialists are typically not involved in the multidisciplinary approaches of treating a pain patient early enough in his or her treatment, which can lead to suboptimal patient outcomes," the task force writes.

In the draft report, the task force notes that an estimated 50 million people in the United States experience chronic daily pain, which has a significant impact on the lives of 19.6 million of them. The Comprehensive Addiction and Recovery Act of 2016 called for the establishment of this task force, which has 29 members. It includes federal officials and pain experts who work in both academia and private practice. The task force is overseen by HHS and the departments of Veterans Affairs and Defense. After receiving public comments, the task force intends to submit a final set of recommendations to Congress in 2019.

Opioid Epidemic

In the draft report, the task force examined the underlying causes of the nation's current opioid epidemic.

The treatment of pain in the United States began to undergo significant changes in the 1990s, with recommendations that clinicians consider patients' reported pain scores as a "5th vital sign," the task force says in its report.

There was aggressive marketing of newer opioid products at a time of limited coverage for other options for pain management. Hospital administrators and regulators pressed aggressive treatment to lower pain scores, while also increasing the bureaucratic demands on them, particularly those generated by electronic health records [EHRs].

"The administrative burden of using the EHR contributes significantly to physician burnout, likely affecting their capacity to manage the complexity of pain care," the task force writes. "As the mandate for improved pain management has increased, there was and remains a need for greater education and greater time and resources to respond to the greater needs of patients with painful conditions."

The number of 2017 overdose deaths involving opioids, including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl, was six times higher than in 1999, according to the Centers for Disease Control and Prevention (CDC). The CDC has said that the current mortality rate averages to 130 Americans dying each day from an opioid overdose.

The CDC describes the epidemic as having three waves, starting with abuse of prescription painkillers in the 1990s. The second wave starting around 2010 was marked by rapid increases in overdose deaths involving heroin.  The third wave, starting around 2013, has been marked by overdose deaths involving synthetic opioids — particularly those involving illicit fentanyl.

In the draft report, the federal task force notes the challenges in trying to address the opioid epidemic simultaneously on a number of fronts, including the unintended consequences of policies.

Successes in curbing opioid prescriptions through state monitoring programs, for example, may have caused some clinicians to refuse to provide prescriptions for people who were on a stable regimen with these drugs, the task force says in the report. Desperate to continue taking narcotics, some of these patients then may have turned to illicit drugs, including fentanyl and heroin, the task force says.

G. Caleb Alexander, MD, of the Johns Hopkins Center for Drug Safety and Effectiveness in Baltimore, Maryland, told Medscape Medical News that the draft report adds to a growing number of calls from medical groups for new approaches to pain management. He said it offered many good suggestions, especially its emphasis on multimodal strategies.

Still, Alexander sounded a note of caution about clinicians trying to predict how likely a patient may be to suffer ill effects from opioids.

"For far too long, we have assumed that we can use risk mitigation measures such as patient screening to appropriately channel patients to opioids vs nonopioid therapies," Alexander said. "The bottom line is that opioids are inherently high-risk products and also not terribly effective for the treatment of chronic pain, so we need to be sure that we don't invest more in patient screening, patient contracts, urine toxicology testing, or other risk mitigation measures than they can deliver."

The task force says its work is meant in part to build on the CDC's 2016 opioid guideline. In the draft report, the task force raised questions about the CDC's guidelines, such as a general limit of opioids for acute pain to 3 or fewer days, saying that a "more even-handed approach" could result in less "workflow disruption" for clinicians while letting patients get their painkillers in "a timely manner."

Other Suggestions

Among the other suggestions from the task force's draft report are:

  • Use multidisciplinary approaches for perioperative pain control such as preoperative psychology, screening and monitoring, and planning for managing pain of moderate to severe complexity. Clinicians may also consider preventive analgesia with nonopioid medications; and regional anesthesia techniques, such as continuous catheter-based local anesthetic infusion, the report states.

  • Have the Centers for Medicare & Medicaid Services and other insurers align their reimbursement guidelines for nonopioid pharmacologic therapies with current clinical practice guidelines.

  • Consider acupuncture, mindfulness meditation, movement therapy, art therapy, massage therapy, manipulative therapy, yoga, and tai chi in the treatment of acute and chronic pain.

  • Conduct more research on these complementary approaches to determine therapeutic value, risk and benefits, mechanisms of action, and economic contribution to the treatment of various pain settings.

  • Seek to counter societal attitudes that equate pain with weakness by launching a public relations campaign. It would encourage early treatment for pain that persists beyond the expected duration for that condition or injury.

  • Address the stigma and perceived racial bias seen in connection with treatment of pain for people with sickle cell disease.

More information on the Pain Management Best Practices Inter-Agency Task Force report is available on the HHS website.

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