Best Pain Management Practices Outlined in New HHS Report

Batya Swift Yasgur, MA, LSW

June 06, 2019

A federal advisory committee issued its final report on recommended best practices for acute and chronic pain, calling for a "balanced, individualized, patient-centered approach."

The Pain Management Best Practices Inter-Agency Task Force had issued a draft of the report in December, asking for public comments, which are incorporated in this final report.

"I think this is a very balanced approach, emphasizing individualized care and patient-centeredness because chronic pain doesn't exist in a vacuum," Vanila Singh, MD, chief medical officer at the HHS Office of the Assistant Secretary of Health and chair of the Pain Management Inter-Agency Task Force, told Medscape Medical News.

"The report gives clinicians best-practice guidelines, not only in chronic pain but also in terms of how to approach patients with comorbid conditions, substance abuse or risk, and how to bring it all together," she said.

The report was released May 10.

Dual Crisis

The task force was convened by the US Department of Health and Human Services (HHS), in conjunction with other governmental agencies, "to address acute and chronic pain in light of the ongoing opioid crisis."

The task force consisted of members of relevant HHS as well as non-federal representatives representing diverse disciplines and views, including experts in areas related to pain management, pain advocacy, addiction, recovery, substance use disorders, mental health, and minority health.

Patients, representatives from veterans service organizations, the addiction treatment community, and groups with expertise in overdose reversal (including first responders, medical boards and hospitals) were also included.

The task force considered medical and scientific literature, information provided by experts, and input from the general public.

"We had an incredible number of organizations that provided comments, lauded, and supported our draft report — not only the American Medical Association (AMA) but other physician organizations, psychological organizations, and social worker organizations. In fact, over 140 organizations came in support and provided insight, which is very unusual," said Singh.

"We also had 9000 public comments, the vast majority being patients, families, or caregivers with heartbreaking stories — some people considering suicide or having done so because of the pain," she continued.

"In addition, we had about 15 patients in public meetings who gave testimonials about being stigmatized, and we were very moved because we found that sharing such personal information was very commendable."

Singh emphasized that an estimated 50 million American adults experience chronic daily pain, and of these 19.6 million have high-impact pain that affects their ability to work, function, and have a good quality of life. "So there is a dual public health crisis," Singh said. "Not only a drug crisis but also a pain crisis."

The report puts forth "four cross-cutting policies to provide the framework for best practices: access to care, education, addressing stigma — which is a big one — and risk assessment," Singh stated.

Therapeutic Alliance

The reports states that, although conducting a "proper evaluation" and establishing a diagnosis are critical in developing an effective treatment plan, it is also important to set "measurable outcomes that focus on improvement, including quality of life (QOL), improved functionality, and activities of daily living (ADL)."

"These are some of the domains that are impaired in people with chronic pain," said Singh.

An individualized, patient-centered approach for diagnosis and treatment is "essential to establishing a therapeutic alliance between patient and clinician," write the authors.

This alliance contributes to "strong collaboration" between the patient and provider, an important component of "better opioid prescribing stewardship."

For acute pain, the authors recommend a "multimodal approach" that includes medications, nerve blocks, physical therapy, and other modalities.

For chronic pain, a multidisciplinary approach across many specialties and disciplines should be implemented, using one or more treatment modalities that include five broad treatment categories.

One category is medication, which includes both opioid and non-opioid agents, with drug choice based on pain diagnosis, mechanisms of pain, and related comorbidities.

A critical aspect of medication selection includes a risk-benefit analysis, which is "so important, and if a person starts taking opioids, it is essential to assess if the risk-benefit makes sense," Singh commented.

In addition, this risk-benefit assessment, Singh said, is important both for ensuring best clinical outcomes and for protecting public health (ensuring safe medication storage and appropriate disposal of excess medications).

Beyond Pharmacology

The authors point out that the 2016 guidelines issued by the Centers for Disease Control and Prevention had "unintended consequences" caused by misinterpretation, including "forced tapers and patient abandonment."

They note that the CDC recently published a "pivotal article" reiterating that its guideline has been "misinterpreted or misapplied," and clarifying their intentions.

"I encourage everyone to read this article," said Singh.

She added that the US Food and Drug Administration (FDA) also issued a safety announcement in April regarding opioid tapering and patient harm caused by forced tapering.

The multidisciplinary approach to pain integrates nonpharmacologic approaches:

  • Restorative therapies (eg, physiotherapy, therapeutic exercise, and other movement-based modalities)

  • Interventional approaches (eg, image-guided and minimally invasive procedures, trigger-point injections, radio-frequency ablation, cryoneuroablation, neuromodulation)

  • Behavioral approaches for psychological, cognitive, emotional, behavioral, and social aspects of pain

  • Complementary and integrative health (eg, acupuncture, massage, movement therapies such as yoga and tai chi, and spirituality)

  • Biopsychosocial model of care that takes into account biological, psychological, and social factors

One of the greatest obstacles to effective pain management is lack of access to effective care.

The authors recommend "addressing the gap in our workforce for all disciplines involved in pain management."

Moreover, they call for improved insurance coverage and payment, stating that it should include coverage and payment for care coordination, complex opioid management, and telemedicine.

Access Still an Issue

Since many patients have access to only a primary care provider (PCP), it is essential to dedicate education, time, and financial resources to PCPs.

"We need more timely reimbursement, no delayed authorization for the very important modalities that we recommend," Singh said.

"Reimbursement for complex conditions is limited and a lot of PCPs have only 5 to 10 minutes to see those complicated patients, so we recommend improvements to reimbursement," she continued.

Singh noted that another area for improving access is reducing administrative burden on physicians, including electronic health records (EHRs), which "have to be innovated, streamlined, and easy to use so as not to distract the doctor from the patient — that was a big thing that we heard."

"In the current environment, patients with chronic pain — particularly those being treated with opioids — can be stigmatized, a tendency exacerbated when their pain condition is complicated by mental health co-morbidities," the authors observe.

The report focuses on populations with unique issues that affect pain management, including active duty service members and veterans; pediatric patients; older adults; women; pregnant women; individuals with sickle cell disease; those with chronic, relapsing pain conditions; patients with cancer and those in palliative/hospice care; and Alaska natives, American Indians, African Americans, and Hispanic/Latino Americans.

The authors highlight the needs of elderly patients, stating that the specific risks in prescribing certain medications to older adults "should not necessarily be an automatic reason not to give this medication to an elderly patient."

In particular, "there is a need for opioid prescribing guidelines for the aging population that provide the potential for increased risk of falls, cognitive impairment, respiratory depression, organ metabolism impairment, and age-related and non-age-related pain issues."

The decision must be based on a risk-benefit analysis, the authors note.

Important Role for Psychiatrists

Singh emphasized that psychiatrists "can play a very important role" in pain management.

"Psychiatrists understand specifically how anxiety and depression can present as a result of chronic pain and can definitely appreciate comorbid conditions, such as a mood disorder, that might already be present," she observed.

The behavioral health section of the report "very much speaks to the expertise of psychiatrists, specifically calling for early referral to a psychiatrist when people have a comorbid mood or substance use disorder or opioid use disorder," she continued.

"If a PCP is facing a patient, maybe one with established chronic pain, psychiatric consultation should be considered early — even a one-time consultation to help with a blueprint for treatment."

Patients with psychiatric comorbidities, Singh said, "are at particular risk, if not addressed early, of losing a job and really spiraling out to a place where the depression could get worse, the person could become socially isolated, not able to take care of him or herself, and not having quality of life."

The behavioral health section of the report emphasizes access to evidence-based psychological treatments, interventions that are often limited by geographical and reimbursement issues.

"We really want to ensure that the gamut of behavioral health and psychological interventions are available, not only at the in-person clinic visit but also via telehealth, validated mobile apps, group sessions, telephone counseling, and other models," she said.

She encouraged psychiatrists and psychologists "to help educate their physician colleagues and other healthcare providers on the benefits of psychological and behavioral health treatment modalities, when clinically indicated."

In general, the report emphasizes education about pain conditions and their treatment for patients, families, caregivers, clinicians, and policymakers.

In particular, clinician training should occur at all levels, including undergraduate, graduate, and continuing professional education, using "proven innovations" such as the Extension for Community Healthcare Outcomes (ECHO).

"This is important so that everyone can get on the same page regarding pain, and how to approach it," Singh said.

Best Guidelines Ever

Commenting on the report for Medscape Medical News, Ajay Wasan, MD, vice chair for pain medicine, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, said that he has "only positive things to say" about it.

"I think it's the best guidelines put together for pain management that I've ever seen," said Wasan, who is also the president-elect of the American Academy of Pain Medicine. "It does a good job of illustrating the benefits of individual treatment and also the understanding that all treatment doesn't work for everyone, and there is some evidence for each treatment in selected patients."

Wasan, who was not associated with the report, called the approach to opioids "excellent" and balanced, noting that in some patients with acute or chronic pain, opioids might be indicated, "which is an important correction to the pendulum that has swung very far against balanced pain management."

Singh noted that the report provides a special section on federal resources, "containing rich input on what is going on at the government level."

"I call on people [in the healthcare professions] to be collaborative and help each other so that patients can have the best clinical outcomes, since this issue touches almost every specialty," she added.

The authors of the HHS report and Wasan have disclosed no relevant financial relationships.

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