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 that since June of 2021 over 100,000 Americans die in the preceding year. At the same time, nearly 100 million Americans experience chronic pain and are often prescribed opioid painkillers. So it is vital that there is clear understanding of chronic pain, in order 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.
  

• 23.4 million American adults report a lot of 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, reducing unnecessary prescriptions and increasing access to effective non-opioid forms of pain management are important strategies states can use to confront the opioid overdose epidemic.

Key Information

The Pain Management inter-agency task force introduced 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.  The report recommends a multi-disciplinary approach that utilizes more than one treatment modality. These include the following treatment categories:

• Medications
• Restorative Therapies
• Behavioral Approaches for psychological, cognitive, emotional, behavioral, and social aspects of pain
• Complementary and Integrative Health, including treatment modalities such as acupuncture, massage, movement therapies (e.g., yoga, tai chi), and spirituality.
• 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
   

Managing Chronic Pain
8 Million Americans are on long-term opioid therapy for chronic pain and 1 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

Experts say chronic pain sufferers on high doses aren’t necessarily addicts, at least not the sort who would resort to buying drugs on the street. With most medical and government resources focused on treatment for more obvious drug abusers, few formal programs exist to help patient's dependent on opioids. Experts who have studied opioid dependence say that, in some cases, it’s too risky to reduce doses until complex psychological problems are under control.

Current Status
Expanding and improving pain prevention programs is a hot topic among public health officials. In March 2016, the National Institute of Health released its National Pain Strategy that outlines the federal government's first coordinated plan to address America's pain crisis. One of the cornerstones of the strategy is the prevention of chronic pain.

Relevant Research

The DiscovEHR Project

A researcher from Florida Atlantic University's Charles E. Schmidt College of Medicine has received 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.

In the novel study, researchers will assess clinical and genetic characteristics of a large patient cohort suffering from chronic musculoskeletal pain and receiving prescription opioids. As part of the project, researchers will leverage data from Geisinger's central biorepository and electronic health record (EHR) database to conduct large-scale genomics research and phenotype development.

With the genetic information, the multidisciplinary team will derive a clinical and genetic profile of prescription opioid-use disorder and apply the knowledge to 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 study will help the researchers determine if there is a particular subset of genes and genetic variants that are influencing susceptibility to becoming addicted to prescription opioids. Once they are able to generate the hypothesis that a genetic variant is responsible for increasing risk, the next steps will involve proving causation. Ultimately, the researchers hope their work will be used to help empower patients so that they understand their susceptibility to risks and can make informed health care decisions.

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.

Available Tools and Resources

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

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.

Promising Practices

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

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

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 define key elements of and the resources required for these models, and identifies patients who are most likely to benefit from these models.​​​​​​​