Perspective

HHS task force outlines best practices for pain management, seeks input

The Pain Management Best Practices Inter-Agency Task Force — an entity within HHS — recently issued a 91-page report detailing best practices on pain management and issued a request for public input on the report.

“The experience of pain has been recognized as a national public health problem with profound physical, emotional, and societal costs. Today, chronic pain affects an estimated 50 million U.S. adults,” the report stated. “Pain management stakeholders have been working to improve care for those suffering from acute and chronic pain in an era challenged by the opioid crisis.”

The task force’s report is based on comments obtained during two public meetings in 2018 and input from 29 experts who, HHS said, have “significant experience” in the areas of pain management, patient advocacy, substance use disorders, mental health and minority health. It provides considerations for the specific pain management needs of children, women, older adults, American Indians/Alaskan Natives, active duty soldiers/veterans and patients with chronic relapsing conditions such as sickle cell disease.

Man with Back Pain 
The Pain Management Best Practices Inter-Agency Task Force — an entity within HHS — recently issued a 91-page report detailing best practices on pain management.
Source:Adobe

According to the report, the best practices were centered on these concepts:

  • balanced pain management should be based on a “biopsychosocial model” of care;
  • better and safer opioid stewardship must be ensured through risk assessments based on patients’ medical, family and social history to ensure safe and appropriate prescribing;
  • better understanding of the mechanisms of pain, preventive measures, and using “innovative” medical devices and medications to prevent the acute-to-chronic pain transition, and methods to improve outcomes of chronic pain conditions should be researched;
  • drug shortages that might impact acute and chronic pain care should be addressed;
  • empathetic and nonjudgmental approaches should be utilized to improve treatment and outcomes to overcome the stigma that is often a barrier to treatment;
  • improved health care coverage for various treatment modalities and a larger workforce of pain specialists and behavioral health clinicians to help guide and support appropriately trained primary care clinicians to ensure access to care;
  • individualized, patient-centered care should be used, as it is “vital” to addressing the public health pain crisis;
  • innovative solutions to pain management such as mobile apps for psychological and behavioral newer medicines and medical devices, telemedicine and tele-mentoring should be part of the overall approach to pain management;
  • multidisciplinary approaches to chronic pain that focus on the patient’s medical
  • condition, co-morbidities, and various aspects of care including behavioral health/psychological interventions, complementary and integrative health; interventional procedures, restorative movement therapies and medications;
  • multimodal approaches to acute pain in the burn, injury, surgical and trauma setting;
  • perioperative surgical home and acute pain guidelines that provide a framework for
  • improved patient experience and outcomes; and
  • provider education and training, societal awareness and patient education are needed to understand choices and promote therapeutic alliances between patients and providers.

The Pain Management Best Practices Inter-Agency Task Force report also sought to clarify the purpose of the CDC’s 2016 guidelines for pain management, saying it was a tool for primary care physicians to help inform their decisions about managing pain with opioids and to encourage dialogue and discussion of risks between PCPs and patients. The report also adds that though CDC 2016 guidelines were not meant to be model legislation for states to act on, 28 states did so.

Moving forward, the CDC will pursue updated scientific evidence regarding the duration of opioid effectiveness for chronic pain and identifying the sub-population of patients for whom opioids may make up a significant part of pain management, according to the report.

The CDC will also try to expand or emphasize the following in the future:

  • factors that lead to optimal opioid dosing;
  • guidelines that clarify opioid tapering and escalation;
  • causes of worsening pain;
  • pain duration following burn, surgery and/or trauma; and
  • benefit of co-prescribing benzodiazepines with opioids in patients who have chronic pain and comorbid anxiety and/or chronic pain and spasticity.

The best practices have been posted for review and public comment on the Federal Register website: https://www.federalregister.gov/documents/2018/12/31/2018-28403/request-for-public-comments-on-the-pain-management-best-practices-inter-agency-task-force-draft. Input will be accepted until April 1, 2019. The report will then be finalized and sent to Congress, the task force stated.

Congress 
The report detailing best practices on pain management and issued a request for public input on the report will ultimately be sent to Congress.

Source:Shutterstock

In a separate statement, HHS also recently provided new guidance regarding prescribing or co-prescribing naloxone and providing education about this treatment in patients at high risk for opioid overdose.

These latter strategies, which do not require Congressional action, recommend clinicians strongly consider prescribing or co-prescribing naloxone and providing education about its use to those:

  • prescribed opioids at a daily dosage of 50 morphine milligram equivalents or more, reported excessive alcohol use; or were prescribed benzodiazepines;
  • diagnosed with a nonopioid substance use or mental health disorder, or, regardless of opioid dose, diagnosed with a respiratory condition such as obstructive sleep apnea or COPD.
  • used heroin, illicit synthetic opioids or are misusing prescription opioids; stimulants, including cocaine and methamphetamine;
  • received treatment for opioid use disorder, including medication-assisted treatment with buprenorphine, naltrexone or methadone; and
  • misused opioids in the past and were also recently released from prison or other controlled settings where tolerance to opioids has been lost.

HHS said this particular guidance was based on data that suggest less than 1% of patients to whom clinicians should consider co-prescribing naloxone actually receive a naloxone prescription. – by Janel Miller

The Pain Management Best Practices Inter-Agency Task Force — an entity within HHS — recently issued a 91-page report detailing best practices on pain management and issued a request for public input on the report.

“The experience of pain has been recognized as a national public health problem with profound physical, emotional, and societal costs. Today, chronic pain affects an estimated 50 million U.S. adults,” the report stated. “Pain management stakeholders have been working to improve care for those suffering from acute and chronic pain in an era challenged by the opioid crisis.”

The task force’s report is based on comments obtained during two public meetings in 2018 and input from 29 experts who, HHS said, have “significant experience” in the areas of pain management, patient advocacy, substance use disorders, mental health and minority health. It provides considerations for the specific pain management needs of children, women, older adults, American Indians/Alaskan Natives, active duty soldiers/veterans and patients with chronic relapsing conditions such as sickle cell disease.

Man with Back Pain 
The Pain Management Best Practices Inter-Agency Task Force — an entity within HHS — recently issued a 91-page report detailing best practices on pain management.
Source:Adobe

According to the report, the best practices were centered on these concepts:

  • balanced pain management should be based on a “biopsychosocial model” of care;
  • better and safer opioid stewardship must be ensured through risk assessments based on patients’ medical, family and social history to ensure safe and appropriate prescribing;
  • better understanding of the mechanisms of pain, preventive measures, and using “innovative” medical devices and medications to prevent the acute-to-chronic pain transition, and methods to improve outcomes of chronic pain conditions should be researched;
  • drug shortages that might impact acute and chronic pain care should be addressed;
  • empathetic and nonjudgmental approaches should be utilized to improve treatment and outcomes to overcome the stigma that is often a barrier to treatment;
  • improved health care coverage for various treatment modalities and a larger workforce of pain specialists and behavioral health clinicians to help guide and support appropriately trained primary care clinicians to ensure access to care;
  • individualized, patient-centered care should be used, as it is “vital” to addressing the public health pain crisis;
  • innovative solutions to pain management such as mobile apps for psychological and behavioral newer medicines and medical devices, telemedicine and tele-mentoring should be part of the overall approach to pain management;
  • multidisciplinary approaches to chronic pain that focus on the patient’s medical
  • condition, co-morbidities, and various aspects of care including behavioral health/psychological interventions, complementary and integrative health; interventional procedures, restorative movement therapies and medications;
  • multimodal approaches to acute pain in the burn, injury, surgical and trauma setting;
  • perioperative surgical home and acute pain guidelines that provide a framework for
  • improved patient experience and outcomes; and
  • provider education and training, societal awareness and patient education are needed to understand choices and promote therapeutic alliances between patients and providers.

The Pain Management Best Practices Inter-Agency Task Force report also sought to clarify the purpose of the CDC’s 2016 guidelines for pain management, saying it was a tool for primary care physicians to help inform their decisions about managing pain with opioids and to encourage dialogue and discussion of risks between PCPs and patients. The report also adds that though CDC 2016 guidelines were not meant to be model legislation for states to act on, 28 states did so.

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Moving forward, the CDC will pursue updated scientific evidence regarding the duration of opioid effectiveness for chronic pain and identifying the sub-population of patients for whom opioids may make up a significant part of pain management, according to the report.

The CDC will also try to expand or emphasize the following in the future:

  • factors that lead to optimal opioid dosing;
  • guidelines that clarify opioid tapering and escalation;
  • causes of worsening pain;
  • pain duration following burn, surgery and/or trauma; and
  • benefit of co-prescribing benzodiazepines with opioids in patients who have chronic pain and comorbid anxiety and/or chronic pain and spasticity.

The best practices have been posted for review and public comment on the Federal Register website: https://www.federalregister.gov/documents/2018/12/31/2018-28403/request-for-public-comments-on-the-pain-management-best-practices-inter-agency-task-force-draft. Input will be accepted until April 1, 2019. The report will then be finalized and sent to Congress, the task force stated.

Congress 
The report detailing best practices on pain management and issued a request for public input on the report will ultimately be sent to Congress.

Source:Shutterstock

In a separate statement, HHS also recently provided new guidance regarding prescribing or co-prescribing naloxone and providing education about this treatment in patients at high risk for opioid overdose.

These latter strategies, which do not require Congressional action, recommend clinicians strongly consider prescribing or co-prescribing naloxone and providing education about its use to those:

  • prescribed opioids at a daily dosage of 50 morphine milligram equivalents or more, reported excessive alcohol use; or were prescribed benzodiazepines;
  • diagnosed with a nonopioid substance use or mental health disorder, or, regardless of opioid dose, diagnosed with a respiratory condition such as obstructive sleep apnea or COPD.
  • used heroin, illicit synthetic opioids or are misusing prescription opioids; stimulants, including cocaine and methamphetamine;
  • received treatment for opioid use disorder, including medication-assisted treatment with buprenorphine, naltrexone or methadone; and
  • misused opioids in the past and were also recently released from prison or other controlled settings where tolerance to opioids has been lost.

HHS said this particular guidance was based on data that suggest less than 1% of patients to whom clinicians should consider co-prescribing naloxone actually receive a naloxone prescription. – by Janel Miller

    Perspective
    Ezekiel Fink

    Ezekiel Fink

    HHS issued new pain-related guidelines based on a multidisciplinary task force whose mission was to determine whether gaps in, or inconsistencies between, best practices for acute and chronic pain management exist, and to propose updates and recommendations to those best practices. The resulting recommendations address a greater range of topics than the 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain and thus serve as a robust step in addressing the opioid crisis while recognizing a broader existing pain spectrum. 

    For example, the HHS guidelines aspire to provide greater guidance to clinicians for specific disease states (eg, back pain, arthritis, neuropathy) as well as address medication shortages and need for more research in the field of pain. These guidelines also address the stigma of substance use disorder and will hopefully serve as a vehicle for more significant conversations between health care providers and their patients in this challenging area. It is my hope and expectation that the HHS guidelines will forward the effort to address the opioids crisis while improving the efficacy of care for acute and chronic pain patients.  

    In April 2018, Houston Methodist was the first health system to completely implement the CDC Guidelines for Prescribing Opioids for Chronic Pain into our electronic health care record for primary care to provide safe and efficacious pain management to our patients. We are also currently piloting a Pain Collaborative among the many excellent Health Systems in the Texas Medical Center to address the opioid epidemic and efficacious pain management. Our initial goals include: linking all the EDs in Texas Medical Center to identify patients at risk for substance misuse, and creating a uniform educational and treatment pain management platform for all practitioners in the Texas Medical Center.

    We welcome the step taken by HHS and look forward to being actively involved in the design and implementation of these new guidelines.

    • Ezekiel Fink, MD
    • Director of Pain Management, Houston Methodist Hospital

    Disclosures: Fink reports no relevant financial disclosures.

    Perspective
    Stefan Kertesz

    Stefan Kertesz

    A recent nudge from HHS to encourage naloxone for patients on long-term opioids and at high risk is helpful. While naloxone can be helpful in treating opioid overdose, HHS and other agencies now need to recognize that preventing catastrophic overdose events will require even greater care than most insurers or regulators have shown to date. Current CDC data reveal that the number of opioid overdose events involving typically prescribed opioids (and no heroin or fentanyl) remains constant at between 8,500 to 10,000 patients a year, despite opioid prescribing per capita being 19% lower than it was in 2006. Since we have not reduced the type of overdose that most involves patients treated for pain who receive opioids, we need to reexamine the evidence on how best to protect this important population.

    The research on how opioid-receiving patients wind up dead shows us that it's not just getting too high a prescribed dose that explains this tragedy, even if dose matters. Instead, in patients receiving prescriptions, the events we call overdose typically involve a combination of prescribed and non-prescribed substances, along with emotional distress and medical problems, leading to chaos. What does that mean for health care?

    The best protection for patients who receive long-term opioids involves getting them into care relationships where the health questions and the medications can be managed comprehensively. The worst risk to patients who receive long-term opioids is what many policies from insurers and government agencies now entail: threatening or warning doctors who have patients on opioids and telling them they are at risk based on the number of patients at a given dose. Sadly, the latter initiatives are increasingly popular among health care quality arbiters, state authorities, and even the U.S. Department of Justice. The effect of these policies is to push doctors to abandon their patients with pain, as those patients inevitably come to feel like liabilities.

    Right now, a lot of doctors are operating out of fear. A lot of my colleagues cut opioids for long-term pain patients in order to rid themselves of a liability. As long as regulators and payers incentivize care in this way, patients cannot be optimally protected, and many will be harmed.

    Hospitals, health systems and/or insurers could do far better. They should set up multidisciplinary teams to provide guidance to doctors who are worried about their long-term pain patients who receive opioids. Those teams can review the records, provide safety tips, and help the clinician identify rehabilitation resources and make cautious decisions regarding opioids. Those decisions need to be individualized for the patient's situation. Patients who have long-term pain and complex opioid challenges may need case management and review to stop them from being abandoned.

    Similarly, HHS should have CMS encourage clinicians to coordinate care for complex patients with long-term pain. CMS and others should promote outcomes measures that track what is actually happening to pain patients, rather than just tracking their prescriptions. That includes checking whether patients live or die after opioids are increased, decreased or stopped.

    Recent reports from an HHS Task Force and a CDC advisory group expressed similar concerns. Both recognized that pain care should be sensitive to individual needs. Both highlighted ongoing risks from narrowly construing opioid dose, and dose alone, as the definition of whether care is good or bad.

    • Stefan Kertesz, MD, MSc
    • Primary care physician, professor of preventive medicine at the University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center

    Disclosures: Kertesz reports receiving federal grants to support research projects and previously holding stock in Abbot and Merck. The views he wrote here are his own and do not represent positions of any federal or state agency.

    Perspective
    James A. Langabeer II

    James A. Langabeer II

    The release of the task force recommendations for pain management are comprehensive and provide good direction for managing chronic pain. Their focus on multimodal, noninterventional and community-based strategies are evidence-based.

    Their other report also encourages distribution of naloxone, the life-saving opioid antagonist, which has proven to be very effective at reversing mortality from overdose. However, the recommendation to co-prescribe naloxone for most opioids prescribed seems a bit excessive. Nearly 200 million opioid prescriptions are filled annually, and 2 million people have an opioid use disorder, so a lot of naloxone will be dispensed and never used. From a cost-effectiveness perspective, there probably needs to be a tightening of those guidelines but most certainly, there is a large segment of individuals that would benefit greatly from this guidance.

    Over the long term, we need improvements across multiple dimensions. Specifically, physicians could benefit from more comprehensive guidelines that address how and when to prescribe opioids when patients present with significant mental health or other co-morbidities; when to check prescription monitoring programs and what to do with the results; and where to refer patients who have opioid use disorder. We also need guidance and training on more effective dialogue and communication between patients and physicians, to diagnose risks and strategies for managing potential overdose and patients with opioid use disorder. Guidelines on how to have conversations about substance use disorder would be extremely helpful and will reverse opioid fatalities and other adverse events. 

    Most hospitals do not adequately train on addiction in the ED, because it usually falls outside the realm of the typical ED physician’s training. My clinical trial (HEROES, the Houston ER Opioid System), based at UTHealth in Houston, is tackling the opioid crisis by addressing opioid risks comprehensively through a community-based system of care beginning with those that overdose. We are educating and providing tools to emergency medical services and ED physicians to help improve management of opioid use disorder that present to the ED, so that these specialists can then help their patients make better, more informed decisions. We have already seen significant retention in long-term recovery when medical, behavioral, and community resources are patient-centered and ongoing. When we finish this trial, we can share more evidence and fill in some the clinical gaps that currently exist.

    • James A. Langabeer II, PhD, EdD
    • Professor of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center, Houston

    Disclosures: Langabeer reports no relevant financial disclosures.

    Perspective
    William Eggleston

    William Eggleston

    I agree with the recent recommendations from HHS and the best practices released by the Pain Management Best Practices Task force that co-prescribing naloxone for patients prescribed opioid medications to treat chronic pain is an important step for reducing overdose deaths. The rising number of opioid overdose deaths includes patients who are unintentionally overdosing on their prescription opioid pain medications. Data support that patients prescribed higher opioid doses, prescribed other sedative medications (like benzodiazepines), or who have respiratory diseases (like COPD or sleep apnea) are at a much higher risk of unintentional opioid overdose than patients who do not have these factors. Previous research evaluating the effects of co-prescribing naloxone with opioid pain medications found that the number of overdose deaths was decreased by prescribing naloxone. Additionally, research within my own university has shown that community members are able to administer intranasal naloxone with a high success rate after completing a very brief training.

    Thus, the new HHS guidelines and Pain Management Best Practices Task Force best practices have the potential to reduce one form of opioid overdose death in the United States. Other important steps for reducing opioid deaths include exploring non-opioid options for chronic pain management and further expanding naloxone access with community programs and over-the-counter availability.

     

    • William Eggleston, PharmD, DABAT
    • Clinical assistant professor, Binghamton University School of Pharmacy and Pharmaceutical Sciences, State University of New York

    Disclosures: Eggleston reports no relevant financial disclosures.

    Perspective
    Daniel Warren

    Daniel Warren

    HHS is not focusing its attention on the prevention of opioid use disorder with its guidelines regarding naloxone. Rather, the agency is trying to help an equally important group — those already at risk for opioid overdose, and/or struggling with opioid use disorder. And as highlighted in the draft report on Pain Management Best Practices, there is opportunity to save more lives by making naloxone, and education on its use, more freely available.

    Some health care professionals who prescribe opioids, and some of those patients who take opioids, may wrongly think tolerance to these pills is protective. These groups may think the patient who has been on opioids for a long time is resistant to negative outcomes such as respiratory depression. The recent HHS guidelines to co-prescribe naloxone seeks to right this wrong mindset. Thus, I am very much in favor of the new guidelines.

    This latest effort by HHS is consistent with the proposed quality metric submitted by the American Society of Anesthesiologists, the American Society of Regional Anesthesiology and Pain Medicine and me to CMS approximately 1 year ago. CMS has recently approved this metric on Safe Opioid Prescribing Practices for quality reporting as part of its Merit-Based Incentive Payment System.

    • Daniel Warren, MD
    • Member, American Society of Regional Anesthesia and Pain Medicine
      Deputy Chief, Department of Anesthesiology at Virginia Mason Medical Center, Seattle

    Disclosures: Warren reports no relevant financial disclosures.

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