Expand and Enhance Chronic Pain Prevention and Management

Introductory Paragraph

Trend data from the Centers for Disease Control and Prevention (CDC) indicates that the number of Americans that died of a drug-related overdose has been increasing each year for over a decade, and in the year preceding June of 2021 over 100,000 Americans died. At the same time, nearly 100 million Americans experience chronic pain and are often prescribed opioid painkillers.

The following is offered to provide a clear understanding of chronic pain to implement more alternative pain management strategies:

• Chronic pain occurs when pain last for longer than 3 months.
  

• Today, chronic pain is the most common cause of long-term disability in the U.S.

• Pain affects more Americans than diabetes, heart disease and cancer combined.
  

• 25.3 million American adults suffer from daily pain.
  

• 14.4 million American adults suffer the highest level of pain -- category 4.

There is little evidence to support the long-term use of prescription opioids for noncancer-related chronic pain. In addition, long-term opioid therapy has high risk, such as opioid use disorder and overdose, particularly with high doses. Non-opioid therapies can be effective with less harm. Given the clear risks that opioids pose, it is important to confront the opioid overdose epidemic with strategies that reduce unnecessary prescriptions and increase access to effective non-opioid forms of pain management.

Key Information

Eight million Americans are on long-term opioid therapy for chronic pain. One million are taking dangerously high doses. This creates a dilemma: how to provide the most effective pain treatment for 80 percent of pain patients who are at least risk for opioid addiction while causing the least harm to the remaining 20 percent who are at most risk of developing OUD. It is important to distinguish the risk posed to all chronic pain sufferers from the active harm endured by the subpopulation of those with chronic pain who also have a substance use disorder. This dilemma is made more complex by the fact most resources focus on treatment and few formal programs exist to reduce dependence. Studies on opioid dependence indicate that it is sometimes too risky to reduce dosage until complex psychological problems are resolved.

The Pain Management Inter-Agency Task Force generated a report on best practices for patients managing acute and chronic pain. The task force emphasized patient-centered care in diagnosis and treatment of acute and chronic pain and recommends a multi-disciplinary approach that utilizes more than one treatment modality, including the following treatment categories:

• Medications
• Restorative therapies
• Behavioral approaches for psychological, cognitive, emotional, behavioral, and social aspects of pain
• Complementary and integrative health, such as acupuncture, massage, spirituality, and movement therapies (e.g., yoga, tai chi).
• Health systems and clinicians consideration of client population needs - child/youth, elderly, women, pregnant women, and special population needs such as sickle cell or needs of veterans, cancer patients and other chronic medical diagnosis.
• Risk assessment & risk stratification
• Addressing & reducing stigma
• Education
• Research and development

'Risk factors' for chronic pain include:

• genetics - heritability accounts for 38.4% of the variation in chronic pain risks.
• female gender
• older age (Chronic pain is the primary reason seniors are prescribed opioids.)
• race and ethnicity
• being a military veteran
• low socioeconomic status
• employment status and occupational factors
• history of abuse or interpersonal violence
• anxiety and depression
• existing health problems - fibromyalgia, shingles, arthritis, a weakened immune system
• lifestyle - not eating healthy, not exercising regularly, smoking, or having a drug or alcohol problem
• previous surgery

Relevant Research

The DiscovEHR Project at Florida Atlantic University's Charles E. Schmidt College of Medicine is a five-year, $4 million grant from the National Institutes of Health to help solve the "one-size-fits-all" approach to prescribing opioids for chronic pain. Because of the high heritability, finding the genetic predictors of prescription opioid use disorder is more critical than ever. Currently, little data exists on clinical characteristics and genetic variants that confer risk for opioid use disorder. The DiscovEHR Project is assessing clinical and genetic characteristics of a large patient cohort who suffer from chronic musculoskeletal pain and receive prescription opioids. Data from Geisinger's central biorepository are leveraged to conduct large-scale genomics research and phenotype development to derive a clinical and genetic profile of prescription opioid-use disorder and develop an "addiction risk score." Researchers hope the findings from this study will enable clinicians to identify those who are at low-risk for opioid use disorder from those who are at high-risk and require additional counseling and access to alternative treatment options. The genome-wide association may determine if there is a particular subset of genes and genetic variants which influence susceptibility to addiction to prescription opioids.

Impactful Federal, State, and Local Policies

The Controlled Substances Act places all substances which are regulated under existing federal law into one of five schedules. This legislation includes requirements for pharmacy registration.

The National Institute of Health released the National Pain Strategy which outlined the first coordinated federal plan to address America's pain crisis. One of the cornerstones of the strategy is the prevention of chronic pain.

Available Tools and Resources

SAFE Project:

• SAFE Veterans provides services to connect veterans, active-duty service members, and their families — all military-connected individuals — to the resources they need to address mental health challenges and substance use disorders.
• SAFE Workplaces provides employers and employees, alike, with the tools and resources necessary to address issues of behavioral health and achieve emotional wellbeing in the workplace.
• See the wiki titled "Increase Access to Non-Pharma Therapies" for more detailed information on alternatives to using opioids as pain management.

CDC provides a document, "2022 Clinical Guideline for Prescribing Opioids for Chronic Pain," and a webinar on the topic.

Pain Management Best Practices. This report was generated by the Inter-Agency Task Force created to address acute and chronic pain in response to the opioid crisis.

The National Governors Association has published "Expanding Access to Non-Opioid Management of Chronic Pain - A Guide for Governors."

The Office of National Drug Control Policy (ONDCP) published the "Rural Community Action Guide -- Building Stronger Healthy Drug-Free Communities" which offers a variety of prevention, treatment , and recovery strategies. The is a compilation of qualitative data collected from numerous community organizations. It aims to educate the public by providing an overview of the key challenges rural communities face when addressing the consequences of prescription opioid misuse and the use of illicit substances. The guide also showcases localized efforts implemented to help mitigate the impact of substance use disorder.

Optum Health Education Current Opioid Prescribing Guidelines: Ensuring Safe and Effective Pain Management.

Promising Practices

Project ECHO (Extension for Community Healthcare Outcomes) was developed by Sanjeev Arora, M.D., at the University of New Mexico Health Sciences Center. It is a collaborative model of medical education and care management that helps clinicians provide expert-level care to patients.

Veteran's Affairs Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain. This report reviews multimodal care delivery models that relieve chronic musculoskeletal pain and minimize unintended consequences. It defines key elements for these models and resources needed. It also identifies patients who are most likely to benefit from these models. ​​​​​​​