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The Inter-Agency Pain Management Task Force Final Draft Report on Best Practice: What Providers Should Know

Tina L. Doshi, MD, MHS, who attended the public meetings, delves into the report's recommendations, including its take on the CDC guideline for prescribing opioids.

For an overview of the Task Force and its members, scroll to the end of this article.

 

The HHS Pain Management Best Practices Inter-Agency Task Force held its third and last public meeting, voting to adopt its final draft recommendations1 for acute and chronic pain management, in May 2019.

In terms of general background, HHS established the task force in 2017, in cooperation with the Secretaries of Veterans Affairs and Defense, as part of the agency’s 5-point Strategy to Combat the Opioid Crisis.2 (Read more about the task force and its members below.) The goal of the task force was to identify gaps or inconsistencies in pain management best practices among federal agencies and then to propose recommendations for updating those best practices. In addition, the task force was expected to review the impact of the highly controversial 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

The task force released its original draft report4 in December 2018 and opened it to a 90-day public comment period. A final version of the draft report was adopted at the recent May 9-10, 2019 public meeting based on those comments, and the finalized report is expected at the end of May 2019. In the author’s view, the following are notable highlights of the final draft report.

 

Source: 123RFThe inter-agency task force identified several gaps in current best practice for the management of acute and chronic pain.

Key Gaps and Recommendations Emphasized in the Report1

  1. Fragmentation of pain care and a lack of coherent policy for pain management limit best practices.  Multimodal, non-opioid therapies are often underutilized, particularly in the perioperative and peri-injury settings.  The report recommends the development and use of evidence-informed guidelines created by specialty organizations and associations with expertise in the treatment of pain conditions. The authors recommend a balanced approach to acute and chronic pain management that is individualized, multimodal, and multidisciplinary, and that is based on a biopsychosocial model of care.  Treatment approaches may include medications, restorative therapies, interventional procedures, behavioral health approaches, and complementary and integrative health.
  2. Clinical policies tend to apply simple medication rules to the large population of patients with multiple conditions causing chronic pain.  There are special populations with unique issues that affect acute and chronic pain and often face barriers to comprehensive pain care, including lack of access to pain specialists and lack of evidence-based guidelines for the treatment of acute and chronic pain for their particular condition.  Special populations identified include, but are not limited to:
    • pediatric patients
    • older adults
    • cancer and palliative care patient
    • women, including pregnant patients
    • racial and ethnic minority populations
    • active-duty service members and Veterans
    • individuals with sickle cell disease or chronic relapsing pain conditions.

The Task Force calls for increased awareness and understanding of the unique challenges of each pain patient population, with condition-specific treatment guidelines developed for a more individualized approach.  When clinically indicated, multimodal, collaborative treatment plans that include primary care providers, disease-specific subspecialists, and pain specialists are encouraged.  

3. Tools for risk assessment, such as prescription drug monitoring programs (PDMPs), medical records review, urine drug monitoring, and opioid treatment agreements, are highly variable and inconsistently applied. The report recommends considering use of PDMPs and other risk-stratification tools upon initiation and re-evaluation of opioid therapy, and supported funding to improve interoperability and usability of interstate PDMP programs.  The report also recommends that payers provide sufficient compensation for time and payment for services to implement screening measures that are critical to ensuring safe and appropriate prescribing.

4. Patients living with chronic pain may face major barriers to care due to stigmatization. Increased patient, physician, clinician, non-clinical staff, and societal education regarding the distinct disease processes of acute pain, chronic pain, and addiction, the countering of societal attitudes that equate pain with weakness, and research into understanding the mechanisms of chronic pain are necessary to de-stigmatize pain and allow pain patients to receive appropriate treatment.

5. There are numerous areas for improvement in public, patient, provider, and policymaker education about acute and chronic pain. The report’s recommendations include development of a national evidence-based pain awareness campaign; providing access to educational tools and support for patients, families, and caregivers; improving pain education in professional school curricula; and soliciting input from key and relevant expert stakeholders from appropriate professional associations, clinicians, and patient advocacy groups prior to effecting policy on acute and chronic pain.

6. Drug shortages, insufficient insurance coverage and reimbursement for pain management services, a shortage of clinicians who specialize in pain, lack of research on innovative and effective pain therapies, and concern over regulatory scrutiny create barriers to adequate pain care.  The task force recommends that the FDA make available alternative sources of pain medications in the event of critical drug shortages, that payers provide appropriate reimbursement for pain management services, that training programs expand the pain management workforce, and that public/private partnerships support and accelerate pain research.

 

How About the CDC Guideline?

The task force notes in its draft final report that the CDC Guideline for Prescribing Opioids for Chronic Pain“provides useful general guidance for prescribing opioids that is primarily intended for primary care providers” (PCPs), recognizing “the utility of the 2016 CDC guideline for many aspects of pain management and its value in mitigating the adverse outcomes of opioid exposure.” However, the task force also highlighted several important limitations of the guideline, including selective support of recommendations with low-quality evidence and vague recommendations. 

For example, although the “CDC cited the lack of clinical trials with a duration of one year or longer as lack of evidence for sustained clinical effectiveness of opioids in chronic pain… [t]he Task Force respectfully points out that there is little clinical trial evidence showing that opioids lack clinical efficacy for such patients.”  The task force goes on to explain that “lack of long term efficacy is true for all common medication and behavioral therapy studies,” because long-term studies often face the challenge of patient drop-out due to ineffective treatment. The report also documents how misinterpretation and gaps in the CDC guideline have led to unintended adverse consequences, including misapplication of the guideline to palliative care and cancer populations, enactment of overly broad legislation overriding medical decision making by healthcare professionals, and forced tapering, medication discontinuation or abandonment of many patients with chronic pain on stable long-term doses of opioids. 

The expert opinion of the task force states, “the CDC guideline does not sufficiently emphasize that optimal pain management begins with identification of the cause of the pain and the biopsychosocial mechanisms that contribute to its severity and associated disability,” recommending a “more even-handed approach [that] would balance addressing opioid overuse with the need to protect the patient-provider relationship by preserving access to medically necessary drug regimens, and reducing the potential for unintended consequences.” 

The document goes on to recommend particular areas of the CDC guideline that it believes require updates, emphasis, or expansion, including:

  • studies on long-term efficacy of opioids in the treatment of chronic pain
  • identification of sub-populations for whom opioids may improve pain management
  • consideration of individual patient and disease factors in determining opioid doses that optimize pain relief and minimize risk
  • elucidation of specific guidelines for opioid tapering and escalation
  • careful consideration of risks, benefits, and alternatives to co-administration of opioids and benzodiazepines.

 

The Report’s Impact on Those Who Take Care of Pain Patients

The task force final draft report offers a comprehensive set of practical recommendations to help both healthcare professionals and policy-makers care for patients in pain.  In its careful, balanced approach, the report emphasizes the importance of a multidisciplinary, multimodal, individual approach to pain management, while also proposing strategies to protect patients from harm.  Specifically, the recommendations to develop coherent, evidence-based guidelines, provide better coverage for pain management services, promote the de-stigmatization of pain, improve pain education, and expand the pain management workforce will guide policymakers and help all of us better care for our patients.

Perhaps even more importantly, the task force highlights the very serious limitations and unintended consequences of the 2016 CDC guideline, which many in the community have witnessed firsthand.  Hopefully, the more considered, rational approach put forth in the final report and its implementation will reverse some of the negative unintended consequences of the guideline and lead all of us on a path to providing better comprehensive pain care while reducing opioid-related harm.

 

FOR MORE INFO

What Is the Task Force?

The creation of the task force was announced in August 2017 under the authority of the Secretary of Health and Human Services (HHS), in cooperation with the Secretaries of Veterans Affairs and Defense, as part of the agency’s 5-Point Strategy to Combat the Opioid Crisis.  This comprehensive strategy prioritizes: better addiction prevention, treatment, and recovery services; better data on the opioid epidemic; better pain management; better targeting of overdose-reversing drugs; and  better research on pain and addiction.2  The goal of the task force was to identify gaps or inconsistencies in pain management best practices among federal agencies, propose updates to best practices, issue recommendations on addressing gaps or inconsistencies, provide the public with an opportunity to comment on proposed updates and recommendations, and develop a strategy to disseminate information about best practices.

Who Served on the Task Force?

The Task Force consisted of 29 members, including 12 special government employee members, nine organization representative members, and eight regular federal members. It was chaired by Vanila M. Singh, MD, chief medical officer for the HHS Office of the Assistant Secretary for Health. Federal members included representatives from HHS agencies, the Departments of Veterans Affairs and Defense and the Office of National Drug Control Policy.  Non-federal members included experts in pain management, pain advocacy, addiction, recovery, substance use disorders, mental health, and minority health, as well as patients, representatives from veteran service organizations, the addiction treatment community, and groups with expertise in overdose reversal.  View a full list of the Task Force Members

Other perspectives on this topic:

Last updated on: June 26, 2019
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