Editor’s note: This piece was originally published at Health Affairs Blog on October 4, 2016.
The United States is struggling to deal with an opioid epidemic that is damaging lives, resulting in overdoses, and yet not reducing chronic pain. National initiatives are underway to dramatically reduce access to prescription opioids, but these efforts lack a systematic approach to provide alternative treatments for these patients. Policy changes are urgently needed to provide better care for patients with chronic pain, and in this post, we outline three feasible policy initiatives.
Innovative reimbursement initiatives by the Centers for Medicare and Medicaid Services (CMS) could frame and stimulate use of evidence-based treatment options, and allow health providers to acquire familiarity with non-pharmaceutical treatments. Electronic medical systems could be designed to guide safe opioid tapering and provide prompts to incorporate physical, occupational, vocational, and psychological approaches to the patient’s care. And providers must be trained in state-of-the-art interdisciplinary models of pain treatment and management.
These approaches reflect contemporary evidence for optimal management of chronic pain. The national dialogue must seriously include initiatives that not only reduce use of a dangerous treatment, but also eliminate obstacles to implementation of safer treatments for persons with pain. Unless provided with alternative options, patients who are desperate for pain relief may take matters into their own hands and look to the streets.
Chronic Pain And Opioids: The Landscape
Over 100 million Americans suffer with chronic pain, 25 million of them on a daily basis. In the clinic, a patient’s expression of pain has urgency to it, and doctors are pressed to address pain reports quickly and perhaps with less focus on the future consequences of actions to stop the pain.
Other pressures include CMS’ patient satisfaction questions designed to assess pain management during a hospital stay. These outcomes have been tied to hospital reimbursement through the Hospital Value-Based Purchasing program, and they have resulted in expectation in inpatient settings to intervene quickly and completely to eliminate pain. For example, one of the CMS questions asks, “How often did the hospital staff do everything they could to help you with your pain?”
Now, in response to the opioid epidemic, CMS is proposing to remove financial incentives tied to pain satisfaction items. This proposed revision has been applauded by addiction medicine groups but criticized by pain medicine groups, illustrating both sides of the dilemma.
These pressures may explain how opioids have become so widely used in medical practice. They provide immediate pain relief, but can transition to unsafe, long-term treatment for pain. As much as 3 to 4 percent of the adult U.S. population is prescribed long-term opioid therapy, and there are nearly 19,000 prescription opioid poisoning deaths annually.
Today a person dies from prescription opioid poisoning every 29 minutes. Annual opioid sales are enough to keep every American on opioids around the clock for 1 month.
While over the past 15 years increasing numbers of patients have been using long-term opioid therapy, there has not been a decrease in Americans’ complaints of pain. Recognizing that an opioid prescription does not equate with feeling better in the long run has been difficult for patients and clinicians alike. For these reasons, alternative non-pharmacological treatments—which take time to implement and focus on long-term improvements—remain largely on the sidelines, unavailable to patients and undervalued by health care practitioners and insurance providers.
An associated concern is the belief that chronic pain is a problem best addressed by intervening directly on neurological pain pathways and discrete anatomical regions of the body. Indeed, pain education in medical schools focuses most of its 11 hours on anatomic location of pain, nociceptor activity, and use of pharmacologic treatment. However, we know that chronic pain often does not fit a simple anatomic or physiologic model. Chronic pain is driven by many factors, including genetics, gender, marital and job satisfaction, employment status, disability policy and benefits, as well as emotional responses to pain.
When conceived of as a problem intertwined with many aspects of a person’s life (rather than solely as a sensory event), we can see more easily that pain, as a problem, is affected by circumstances that contribute to profound suffering across many domains. Unfortunately, in the clinic today, the social, psychological, and economic influences that potentiate this suffering are often unaddressed, resulting in poor treatment outcomes.
An Historical Interdisciplinary Model
Historically, medicine did not always ignore the complexities of the pain experience. In the late 1970s, a neurosurgeon, John Loeser, and a clinical psychologist, Bill Fordyce, enlisted doctors and allied health professions to work together to help persons with chronic pain. The treatment they developed addressed the many factors that contribute to pain and treated patients as active participants in therapy. Patients were taught to interpret their pain experience differently, become stronger with physical therapy, and develop self-management skills with the aid of a psychologist that would help them to lead more productive lives.
These treatments worked. Consequently, multidisciplinary pain centers flourished around the country. However, this model of care utilized considerable health service resources and required whole teams to focus on the care of each individual patient. Though patients improved, insurers that were fighting to contain costs stopped paying for multidisciplinary pain care, and most centers did not survive. In 1999, there were over 1,000 multidisciplinary chronic pain clinics in the US, compared to only 90 programs in 2015.
At the same time, physicians treating dying patients began to champion opioids as a means of proving compassionate care for patients with chronic pain who were not dying. Expert panels with limited experience in nonmalignant pain management began to write guidelines for use of opioids in primary care. The guidelines were strong on expert opinion but weak on evidence. Most Food and Drug Administration (FDA) trials required that opioids demonstrate relief over 12 weeks – enough to address immediate symptoms without observation of long-term negative consequences. Pharmaceutical firms that produced and marketed opioids aided the initiative to expand opioid use.
By the mid-1990s, medicine’s view of pain had changed. Surprisingly, a small inpatient sample of 38 cases and an underpowered study that did not detect dependency were cited repeatedly as support for opioids as a safe means of treating chronic pain without causing addiction. On the surface, opioid therapy seemed justified to fill the void left by the decline of multidisciplinary pain centers. Since that time, however, little evidence of long-term benefit has emerged and harms have become abundantly clear.
In response to the opioid crisis, policy leaders are calling for a return to integrated chronic pain treatments. The Food and Drug Administration, the Centers for Disease Control and Prevention, the Surgeon General, and the President of the American Medical Association have each recommended that non-pharmacologic intervention be the first-line treatment for chronic pain. Yet, the pathway to an economically viable, non-pharmacologic approach to pain management remains unclear. Beyond an office visit, an MRI order, and a prescription, integrative care for chronic pain is not easily coordinated or reimbursed. Big changes are necessary to overcome our myopic view favoring immediate pain relief over safer approaches that are effective in the long term.
The Path Forward
Promoting Evidence-Based Non-Opioid Treatments
We believe three policies and practices must be addressed to make non-pharmacologic treatments more widely accessible and reimbursed. First, the multidisciplinary approach seen in the 1970s and 1980s needs to be re-engineered to fit the current health care landscape. CMS needs to take a leadership role in designing innovative approaches. Rather than reacting to the opioid crisis by deemphasizing pain treatment, patients would be better served if CMS encouraged use of evidence-based non-opioid treatments for pain.
For example, CMS should consider a chronic pain shared savings program targeting accountable care organizations (ACOs), where success would be tied explicitly to patient functional outcomes. CMS could develop an objective, functional status benchmark against which ACO performance is measured to determine if care is generating a savings or loss. Organizations that meet or exceed quality performance standards would receive a portion of the savings they generate. This would effectively introduce incentives to use approaches consistent with more effective integrative interventions for pain.
The economics underlying such initiatives are clear: the annual cost of pain ($560 to $635 billion; 2010 dollars) is greater than the annual costs of heart disease ($309 billion), cancer ($243 billion), and diabetes ($188 billion).
Electronic Decision Aids
Second, policymakers need to consider systems that will encourage clinicians to make greater use of evidence-based decision aids. For example, electronic health records could trigger default schedules to taper opioids when they have resulted in inadequate pain reduction or functional impairment. They could introduce standing orders for physical, occupational, and psychological pain management therapies. Routine mental health screening could improve clinician awareness of depression and anxiety that are associated with pain and prompt referrals and care coordination efforts.
These strategies could direct patients toward services that would engage them in musculoskeletal strengthening, protective movement patterns, and self-management of emotional responses to pain. This would allow patients to return to valued life activities.
Rethinking Provider Training
Third, integrative interventions require teams of health providers who have specific training in assessment and delivery of state-of-the-art approaches to pain management. Yet such training is rare in our current health care teams. Exploring a potential solution, we recently completed a National Institutes of Health (NIH)-supported, multi-site, clinical trial that demonstrated the effectiveness of Pain Coping Skills Training (PCST)—an evidence-based 10-visit intervention based on behavioral principles—for osteoarthritis patients with chronic pain.
Whereas originally PCST was developed and delivered by clinical psychologists, this trial demonstrated that nurse practitioners, who are embedded in community medical practices, could achieve comparable outcomes with PCST. Results included reduced pain, fatigue, emotional distress, and use of pain medication relative to a usual care control group.
Based upon this success, we designed a two-and-a-half-day workshop to train nurse practitioners to deliver PCST in their clinical practices. However, right now, such training is not widely available or supported. Effective training of health care teams must include a reconceptualization that engages patients to be active in their own care and recovery, and that abandons the faulty view of patients as passive consumers of pharmaceutical treatment.
The opioid crisis has been a wake-up call for health policy experts and clinicians around the country. It has shown us that a long-term view of pain management is crucial for achieving safe and effective clinical outcomes. However, the path forward is uncertain until we make policy changes to encourage improvements in how care is delivered.
We need to train health care teams and empower patients to better manage pain. Education and guidelines aimed at clinicians are first steps. At the same time, we must develop streamlined interventions, create innovative incentive structures, and build new ways to deliver choices to clinicians.
Preparation of this publication was supported by Pfizer Independent Grants for Learning & Change under Award Number 16004615 to JEB and PB. The content is solely the responsibility of the authors and does not necessarily represent the official views of Pfizer U.S.