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15 Articles in Volume 18, Issue #5
Chronic Pelvic Pain: The Need for Earlier Diagnosis and Diverse Treatment
Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain
Fentanyl: Separating Fact from Fiction
Gender Bias and the Ongoing Need to Acknowledge Women’s Pain
Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain
Post-Menopausal MSK Pain and Quality of Life
PPM Welcomes Dr. Fudin and Dr. Gudin as New Co-Editors
Practitioner as Patient: Understanding Disparities in CRPS
States Take Action to Manage Opioid Addiction
Step-by-Step Injection Technique to Target Endometriosis-Related Neuropathic Pelvic Pain
The Many Gender Gaps in Pain Medicine
The Need for Better Responses to Vulvar Pain
Topical Analgesics for Chronic Pain Conditions
Topical Medications for Common Orofacial Pain Conditions
What’s the safest, effective way to taper a patient off of opioid therapy?

States Take Action to Manage Opioid Addiction

Model programs that address gaps in professional training, treatment access, and insurance coverage are popping up across the country.
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With Lindsey Vuolo, JD, MPH, Paul George, MD, MPHE, Josiah Rich, MD, MPH, and Jeff Gudin, MD

By now, the numbers are familiar but still sobering. Every day in the United States, 116 people die from opioid-related overdoses, including not only prescribed opioids, but also illicit and pharmaceutical fentanyl, as well as heroin, counterfeit drugs, and the mixture of drugs that often lead to fatalities.1 These deaths are just part of the opioid epidemic problem, of course. In 2016, more than 2 million Americans had an opioid use disorder, and another 2 million misused prescription opioids for the first time.1

The opioid crisis is being fought on federal and state levels, with the US Department of Health and Human Services (HHS) focusing efforts on five priorities:

  • Improving access to both addiction treatment and recovery services (view PPM's new PainScan Lit Review on this subject)
  • Promoting the use of medications such as naloxone to reverse overdose
  • Strengthening the understanding of the epidemic through better public health surveillance
  • Providing support for cutting-edge research on pain and opioid addiction
  • Advancing better pain management practices.2

To help the states wage war on the opioid crisis, HHS released a second round of funding in April 2018. In all, 57 grant awards totaling $485 million were parceled out to 50 states, four US territories, and the free associated states of Palau and Micronesia.3 These grants were in addition to the nearly $900 million in opioid-specific funding issued in fiscal year 2017, to states, local governments, and civil society groups.4 Known as the Opioid State Targeted Response Grants, the funds were made possible by the 21st Century Cures Act. The Substance Abuse and Mental Health Services Administration (SAMHSA) within HHS administers the grants, and by September, new funding from a separate $1 billion grant is expected to be awarded.3

While a successful program to combat the crisis has numerous components, three areas are often mentioned by experts as crucial for individual states to address and for practicing physicians to know about. These include: professional training; access to treatment and recovery; and insurance access and coverage.

As the states’ efforts accelerate, and programs become operational, “clinicians are being forced into changing behavior,” said Jeff Gudin, MD, director of pain management and palliative care at the Englewood Hospital and Medical Center in New Jersey and incoming Co-Editor-at-Large for PPM. States’ efforts are already translating into clinical practice changes, he said. For instance, in his state, a new law mandates that prior to an initial prescription for opioids the physician have a discussion with the patient about the risks and alternative treatments.5

Following is a look at the three key ways states are working to improve opioid addiction, misuse, and overdose challenges, including highlights of some model programs.

Professional Training

Professional medical training must include opioid addiction facts, experts concur. “For doctors, the issue has long been that they get little training in medical school about addiction, how to screen for it, how to manage it,” said Lindsey Vuolo, JD, MPH, associate director of health law and policy for the Center on Addiction (formerly the National Center on Addiction and Substance, Abuse), a national nonprofit devoted to solutions for the US addiction crisis.

She was the lead author of a comprehensive report from the center, titled “Ending The Opioid Crisis: A Practical Guide for State Policymakers,” released in October 2017.6 The report lays out what needs to be done, with examples of model programs interspersed throughout.

The challenge is particularly difficult, said Vuolo, for primary care providers (PCPs) managing a large population of patients with a wide range of health conditions. They lack the extent of day-to-day experiences that many pain specialists encounter. However, pain specialists, too, even those who see large numbers of patients for addiction issues, face snags.

According to the Center on Addiction, professional training should educate healthcare professionals to be capable of predicting risky substance use and addiction, and include prevention, intervention, treatment and management; how to handle co-existing conditions; and how to work with populations with special needs, such as incarcerated individuals with co-existing mental health problems, repeat offenders, and juveniles.

Professional training must be provided not only to already licensed physicians, the Center report suggested, but also to physician assistants, nurses, nurse practitioners, dentists and clinical mental health workers. The training, if it is to be effective, must be mandated and made a condition of not only licensure but also for continuing education (CE) credits. In addition, non-healthcare professionals, such as educators, law enforcement, and criminal justice personnel, should be educated about substance use and addiction.6

Another important part of professional training, Vuolo said, is learning how to effectively screen patients and knowing when to provide brief interventions, as well as referrals for treatment – a process known as SBIRT. “Patients should be having that [SBIRT] with any encounter with the healthcare system,” Vuolo said.

Model Training Programs

Vuolo pointed to a program at Brown University as a model of professional training. “They are integrating a comprehensive training program for providers,” she explained. The program also offers opportunities for CME and CEU credits, said Paul George, MD, MHPE, assistant dean for medical education and associate professor of family medicine and medical science at the university’s Alpert Medical School.

Last updated on: March 1, 2019
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