The Pain Management Best Practices Draft Report
The Pain Management Best Practices Draft ReportJanuary 19th, 2019 by Cindy Perlin
Yet another report has been released by the federal government about the treatment of chronic pain. Due to continuing concern about the escalation of the opioid addiction and overdose crisis, the U.S. Department of Health and Human Services Pain Mangement Best Practices Task Force was established. Their assignment was to propose updates to best practices and issue recommendations that address gaps or inconsistencies for managing chronic and acute pain. The recommendations are still in draft form. They are open to public comments until April 1. To read the 56 page draft report click here.
Forced Tapering of Opioids
Chronic pain patients who have been subjected to forced tapering or discontinuation of their opioid medications or are concerned about the possibility will be gratified to see their problems noted in the Pain Management Best Practices report as follows:
“This increased vigilance and targeting of the misuse of prescription opioids and the tightening of their availability have in some situations led to unintended consequences, such as patient abandonment and forced tapering, with established patients with pain possibly transitioning to illicit drugs, including illicit fentanyl and heroin – this would be a separate group of patients distinguished from those with substance use disorders”
“Public comments submitted to the Task Force show growing consideration of suicide resulting from unrelieved pain and in some cases lack of access to treatment. According to a recent CDC report using data from the National Violent Death Reporting System, the percentage of people who died by suicide who also had evidence of chronic pain increased from 7.4% in 2003 to 10.2% in 2014. Numbers from this data set beyond 2014 are not yet available” (Note: this data on suicides precedes the aggressive reduction of opioid prescriptions following the CDC opioid prescribing guidelines released in March, 2016, but after many physicians had been prosecuted for so-called excessive prescribing.)
The Task Force points out that the CDC guidelines were directed towards initiation of opioid therapy, not long term users, and includes as a recommendation: “Consider maintaining therapy for patients who are stable on long term opioid therapy and for whom the benefits outweigh the risks”
Nonpharmacological and Alternative/Complementary Medicine
Those who are strong advocates for giving patients more access to nonpharmacological, alternative and complementary treatments will be gratified to see this and similar recommendations in the report:
“The Task Force recognizes that comprehensive pain management often requires the work of various health care professionals, including physicians, dentists, nurses, pharmacists, physical therapists, occupational therapists, behavioral health specialists, psychologists, and integrative health practitioners. The complexity of some pain conditions requires multidisciplinary coordination among health care professionals.”
What’s missing from the report
The Task Force report lists the availability of many non-opioid medications and interventional procedures, including NSAIDs, anticonvulsants, antidepressants and injections, while failing to report the many risks associated with these medications and procedures.
There is zero mention in the report of medical marijuana for pain relief and treatment of opioid withdrawal, along with a failure to recommend rescheduling of marijuana from Schedule 1 (no known medical benefits and high potential for abuse, which makes marijuana illegal at the federal level) to a more appropriate classification. Likewise, there is no mention of kratom, a safe and effective herbal treatment for pain and addiction that the FDA and DEA are currently trying to ban.
Numerous reports and guidelines over the last few years have recommended increasing access to nonpharmacological/alternative treatments. These recommendations have to date failed to change insurance reimbursement policies, for both government-funded and private insurance. The Task Force report contains similar language:
“CMS and private payors should investigate and implement innovative payment models that recognize and reimburse holistic, integrated, multimodal pain management, including complementary and integrative health approaches.”
It is time to require, not recommend, that all forms of insurance cover all proven effective alternative treatments for pain at a level that ensures access to high quality care. “Innovative payment models” are not necessary. Just require insurance companies, Medicare and Medicaid to pay a reasonable fee for each treatment session provided.
The report notes that “access to behavioral pain management is limited because financial incentives are lacking for psychologists and other providers to specialize in pain. Many insurance programs do not reimburse for behavioral pain treatments, or they reimburse at a much lower rate than for pharmacologic or interventional treatments. Because of the lack of incentives, not enough providers are trained in behavioral pain management.”
This statement vastly underreports the problems with access to behavioral health care. Mental health providers have not seen an increase in their reimbursement schedule by insurance carriers in over forty years, a time period in which the overall inflation rate has far exceeded 300%. This has meant that many providers can no longer continue to provide these valuable services and few young people can afford to enter these fields. Mental health provider shortages are rampant in the U.S. as a result. Federal regulations stipulate that, in order to be considered as having a shortage of providers, an area must have a population-to-provider ratio of a certain threshold.
Here is the federal requirement to be designated a mental health provider shortage area:
Mental health designations may qualify for designation based on the population to psychiatrist ratio, the population to core mental health provider (psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists) ratio, or the population to both psychiatrist and core mental health provider ratios. For mental health geographic designations based on the ratio of population to psychiatrist ratio, the designation must have a ratio of 30,000 to 1, while for population designations or geographic designations in areas with unusually high needs, the threshold is 20,000 to 1. For mental health geographic designations based on the ratio of population to core mental health providers, the designation must have a ratio of 9,000 to 1, while for population designations or geographic designations in areas with unusually high needs, the threshold is 6,000 to 1. For mental health geographic designations based on the ratios of both population to psychiatrist and population to core mental health providers, the designation must have ratios of 20,000 to 1 (psychiatrists) and 6,000 to 1 (core mental health providers), while for population designations or geographic designations in areas with unusually high needs, the thresholds are 15,000 to 1 (psychiatrists) and 4,500 to 1 (core mental health providers).
This level of availability is ludicrous given that 4% of the U.S. population is severely mentally ill, one in six Americans take a psychiatric drug, and over 6% have substance abuse issues. If we add into the mix that the one in three Americans who have chronic pain could benefit from mental health treatment, this low definition of what is adequate mental health provider availability is even more laughable.
Still, using the current definition of mental health provider shortage area, the vast majority of the country is experiencing significant mental health provider shortages. Click on this link to see just how bad it is: https://www.ruralhealthinfo.org/charts/7
It is payment at an unsustainable level that is causing these shortages. Other medical specialties that serve pain patients, including physical therapists, are also experiencing shortages for similar reasons. If more patients were to gain access to alternative treatments such as acupuncture, biofeedback and massage, there would be an extreme shortage of those specialties also. It is time for bold action, including requiring that reasonable fees be paid for provision of these services, not “development of innovative payment models”.
What else is missing from the report
Nutritional and herbal therapies, low level laser therapy, pulsed electromagnetic field therapy and many other alternative therapies that have been proven to be effective for treating pain are ignored in the report. Pain is a complex biopsychosocial problem and all options must be available and funded in order to have a healthcare system that truly serves patients in pain.
How to comment on the report (Instructions from the Department of Human Services)
- Submit through the Federal eRulemaking Portal at http://www.regulations.gov, Docket Number: HHS-OS-2018-0027
(If Regulations.gov is inoperable, as a secondary option please submit your comments to email noted below.)
- Email to: firstname.lastname@example.org(Secondary method)
- Mail written comments to:
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Health
200 Independence Avenue, S.W., Room 736E,
Attn: Alicia Richmond Scott, Task Force Designated Federal Officer
Washington, DC 20201
Written comments should not exceed three pages in length. To assist with the review of public comments, please indicate a specific section, gap and/or recommendation in the report for which the comments are related, for example, Acute Pain, Gap 2 or Recommendation 2a.
Comments that contain references to studies, research, and other empirical data that are not widely available should include copies of the referenced materials with the submitted comments. Comments submitted by email should be machine-readable and should not be copy-protected. Responders are encouraged to include the name of the person or organization filing the comment, in case follow-up is needed, as well as a page number on each page of their submission(s).
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