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.
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.
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