National Pain Strategy—A Positive Step Forward
A group of pain specialists have been working behind the scenes for the past 5 years to develop a National Pain Strategy (NPS), the fruit of their labor is now available for public comment.1,2 Practical Pain Management applauds the work of the taskforce and their recommendations.
As background, the NPS is an offshoot of The Patient Protection and Affordable Care Act (ACA). “The ACA included a number of provisions designed to advance pain research, care, and education, including the creation of the Interagency Pain Research Coordinating Committee (IPRCC) by the Department of Health and Human Services (HHS),” according to the National Institute of Health website.3
The committee involves 6 working groups that tackled various aspects of pain care, including: population research, prevention and care, disparities, service delivery and reimbursement, professional education and training, and public awareness.
At the recent American Academy of Pain Medicine (AAPM) meeting, held in National Harbor, Maryland in March, a number of members of the taskforce presented their findings. The presenters outlined goals and actions to help improve pain care for millions of Americans. “The report does not make specific treatment recommendations; rather it acknowledges evidence gaps and calls for further research to better understand pain in order to treat it more appropriately,” noted Sean Mackey, MD, PhD, immediate past president of AAPM and co-chair of the taskforce. “Although focused on chronic pain, the NPS addresses the continuum of pain from acute to chronic, and across the life span from pediatric through geriatric populations.”
The NPS recommends investing public resources to prevent pain, create access to evidence-based and high-quality pain assessment and treatment services, and improve self-management abilities among those with pain. Self-management is critical, noted the report. “For other chronic diseases including diabetes, COPD, congestive heart failure, etc. significant efforts to provide self-management options have been made for each. The same must be true for those with chronic pain,” noted a press release from the AAPM.4
“Equally important is the role that primary care clinicians as first contact providers play in treating pain. But in order for primary care clinicians and other providers to care for a problem of this magnitude, change is needed. [Such] providers would benefit from education and support from specialists. Reimbursement must be restructured to appropriately incentivize the comprehensive and complex care needed for those suffering in pain,” noted AAPM.
Another vital aspect addressed in the NPS report is the stigma people with pain endure from the health care system and society as a whole. Through better public and professional education, this misconception can be changed and the stigma associated with chronic pain will be reduced.
Individuals may comment on the National Pain Strategy draft by May 20, 2015.2 HHS invites input from a broad range of individuals and organizations that have interests in advancing the fundamental understanding of pain and improving pain-related treatment strategies.
In order to make pain a national public health priority, PPM urges as many individual letters as possible from the public indicating support of the NPS plan and also to provide general feedback.
A seminal study on the relationship between opioids and unintentional overdose has been conducted, providing the first, hard evidence that the risk of unintentional overdose is greater with long-acting opioids rather than short-acting opioids.3 The risk associated with long-acting opioids is particularly marked during the first 2 weeks after initiation of treatment, according to a research team headed by Mathew Miller, MD, ScD, at the Massachusetts Veterans Epidemiology Research and Information Center in Boston. The authors recommend “short-acting agents whenever possible.”
Despite the potential of overdose and endocrine suppression, long-acting opioids still have a place in chronic pain management. In these pages we have repeatedly called attention to 2 guidelines that have, among other goals, intentions to prevent the misuse of opioids. The first is the FDA-labeled indication for long-acting opioids: “use for moderate to severe pain when around-the-clock dosing is indicated.” This means that the patient has constant pain and that trials of short-acting opioids have been insufficient. The second is the World Health Organization (WHO) 3-Step Analgesic Ladder. Long-acting opioids, which are clearly in the “potent” opioid category, are to be added to an existing regimen of non-opioid measures and one or more weak opioids.
For initial therapy, short-acting opioids are preferred to long-acting opioids because of their shorter half-lives and reduced risk for overdose, according to clinical guidelines from the American Pain Society and the AAPM.4 The guidelines further recommend that “opioid selection, initial dosing, and titration should be individualized according to the patient’s health status, previous exposure to opioid, attainment of therapeutic goals, and predicted or observed harms.” Patients should be started on a short-acting opioid, titrated to efficacy, and then switched to a long-acting opioid. This prevents significant opioid-related adverse effects, such as nausea, vomiting, sedation, and respiratory depression.
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