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

Non-Pharmacologic Pain Care (NPPC) or alternative therapies can be used to balance pharmacological and non-pharmacological approaches. There are many benefits of using NPCC, and evidence is growing that this is a promising approach in addressing the opioid crisis. There are three avenues for increasing the use of NPCC alternatives. One pathway is for the medical community to promote alternatives that have been verified as effective. The second is for the public to begin to advocate for increased use of NPCC. The third and most powerful leverage point lies with changing the insurance standards that provide reimbursement for NPCC.

NPCC health approaches include:

• Acupuncture
• Chiropractic care and spinal manipulation
• Massage Therapy
• Stretching and fitness techniques, such as yoga, Tai Chi, and Qi Gong
• Mindfulness and meditation-based therapies
• Biofeedback
• Transcutaneous electrical nerve stimulation (TENS)

Currently, most insurance plans do not cover most NPPC therapies. Working with insurance companies to cover more alternative and complementary pain therapeutic services can decrease opioid prescriptions for pain. Preventing patients from having opiates introduced into their bodies is one of the most effective ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often, people using opiates also use marijuana or other illicit substances to treat their nausea, producing a cycle of dependency which makes treatment harder. In today’s society, patients often have complicated medical histories and multiple medications. Considering alternative and complementary therapies can help them avoid adverse drug reactions and preserve their health. For example, this would decrease stress on both the liver which metabolizes the prescription drug and detoxifies the body and the kidney which excretes the drug. NPPC therapies have less toll on the body, can help patients stay healthier, and improve their quality of life.

In contrast to medication-based therapies, many NPPC strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. The military has studied “active self-care therapies” as a category of pain management which could be of value in an integrated, multi-modal approach.

Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize non-opioid pain management options rather than opioid prescriptions for the treatment of chronic pain. Professor Dr. Andrew Kolodny at Brandeis University maintains that efforts to limit opioid prescribing in recent years have been positive, but warns that there are still 10 to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage of continued use or unmanaged withdrawal.

Relevant Research

This paper examines the effectiveness of NPPC therapies. It includes acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, mind-body behavioral interventions, diet, self-efficacy strategies, and meditative movement therapies such as Tai Chi and yoga.

This article is based upon interviews with eight groups of patients, nurses and primary care providers to identify barriers and successes in the use of NPPC treatments in chronic pain.

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.

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. ​​​​​​​

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.

Federal policy has not been developed to coordinate care across disciplines and to increase access to non-pharmacologic care. Improving state and territorial to state and territorial systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective non-pharmacologic therapies as a first-line treatment option for pain conditions. See Promising Practices section below.

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.

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 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.

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

The Joint Commission works with over 20,000 healthcare organizations in more than 70 countries. It has published a 2-page fact sheet titled "Non-pharmacologic and non-opioid solutions for pain management." The Joint Commission has also published "Pain Assessment and Management Standards for Hospitals" which has guidance on leadership, performance improvement, medical staff, and provision of care, treatment, and services.

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

MyStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement, and evidence-based pain management tools. MyStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. MyStrength enhances traditional care models while addressing issues of cost, lack of access, and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders, and chronic pain. MyStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems, and accountable care organizations.

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

Promising Practices

Project ECHO (Extension for Community Healthcare Outcomes) is a remote training that focuses on treatment of substance use and behavioral health disorders. ECHO was developed by Sanjeev Arora, M.D., at the University of New Mexico Health Sciences Center and features a team of multidisciplinary addiction specialists. It is a collaborative model of medical education and care management that helps clinicians provide expert-level care to patients, and it is offered for free to care providers in the United States. ECHO serves federally-qualified health centers with videoconferencing technology and equips healthcare teams to connect with a community of learners.

The Oregon Health Plan (OHP) is the state's Medicaid program. It covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy, and cognitive behavioral therapy for all back conditions.

Vermont has piloted a program to cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness.