Patient-Centered Care Is Key to Best Practices in Pain Management
On May 10, the Pain Management Best Practices Inter-Agency Task Force voted on its final recommendations, which emphasize the importance of providing balanced, individualized, patient-centered pain management to ensure better clinical outcomes for pain that improve quality of life and functionality for patients. The group recommended a broad framework of approaches for treating acute and chronic pain. Following is an interview with Dr. Vanila Singh on the task force’s work.
Q: Dr. Singh, the Pain Management Best Practices Inter-Agency Task Force, a federal advisory committee that you chaired, just voted on final recommendations for pain management best practices. What was the Task Force's charge?
A: We were charged by section 101 of the Comprehensive Addiction and Recovery Act of 2016 (CARA) to propose updates to best practices and issue recommendations that address gaps or inconsistencies for managing chronic and acute pain.
Q: What were some of your key recommendations?
A: We recommended a multimodal approach for patients who experience acute injury and perioperative pain, as well as a multidisciplinary approach for patients with chronic pain and various underlying pain conditions. Our report emphasizes safe opioid stewardship, recommending approaches that mitigate opioid exposure. These multidisciplinary approaches may include medications (non-opioid as well as opioid, depending on the individual patient's situation), interventional approaches, restorative therapies, behavioral health interventions and other approaches.
Q: What kinds of gaps did the Task Force identify?
A: We identified a number of gaps that need to be addressed in order to improve pain management. We highlight the need for multidisciplinary approaches to chronic pain that focus on the patient's medical condition, co-morbidities and various aspects of care including: medications, restorative movement therapies, interventional procedures, complementary and integrative health services, and behavioral health and psychological interventions. Each multidisciplinary approach would depend on clinical indication and patient specific needs.
In our recommendations, we also underscore the need to address stigma, risk assessment, access to care and education for all stakeholders. Addressing these needs and gaps will help clinicians manage acute and chronic pain in an individualized patient-centered way. The Task Force also identified special populations and certain population-specific circumstances that need to be considered during diagnosis and the development of treatment options.
Q: What did the Task Force say about the CDC Guideline for Prescribing Opioids for Chronic Pain?
A: The Task Force emphasizes individualized patient-centered care when considering pain care. While the Guideline is in line with that, and there has been progress in improving many prescribing behaviors, the Task Force recognizes that, in some cases, the CDC Guideline has been misinterpreted and misapplied. Unfortunately, unintended consequences such as forced tapering and patient abandonment contribute to adverse patient outcomes and provider disincentives in treating patients with complex acute and chronic pain.
These findings are consistent with the FDA safety announcement in April 2019 on opioid tapering and the patient harm due to forced tapering. Also in April 2019, CDC Guideline authors published a perspective piece in the New England Journal of Medicine, indicating that some policies and practices that cite the Guideline are not consistent with its recommendations, or go beyond its recommendations, potentially putting patients at risk. Issues include application of the Guideline to populations beyond the Guideline's intended audience, abrupt tapering or sudden discontinuation of opioids, and misapplication of the dosage recommendation to medication-assisted treatment (MAT) for opioid use disorder. I encourage everyone to read this article.
Q: How does the Task Force address the opioid crisis?
A: The Task Force was created in the midst of a national opioid epidemic, but also at a time when an estimated 50 million adults in the U.S. experience chronic daily pain. It is important to strike a balance between mitigating opioid exposure while ensuring that adequate pain treatments are available for patients to have the best quality of life possible.
Q: Is there a place for opioids in pain treatment?
A: Opioids are an important and necessary component in treating certain pain conditions in certain patients. The decision to prescribe an opioid depends on the patient's condition and the provider's ability to do a proper risk assessment with periodic re-evaluation and thoughtful consideration of the risks associated with opioids. It is important to ensure that the patient is educated on risks and alternatives. The patient's history and medical condition are critical components of this assessment.
The Task Force does not recommend the indiscriminate removal or forced tapering of opioids as a treatment option. We acknowledge that opioids have the potential to lead to physical dependence and possible opioid use disorder, particularly in certain at-risk populations. Risk assessment and periodic re-evaluation and monitoring is required and should be a part of the treatment plan.
The Task Force acknowledges that there is a certain subpopulation of patients whose health outcomes do not improve with non-opioid treatments. Initiation of opioid therapy, when the benefits are deemed by the patient and the clinician to outweigh the risks, should be administered for the shortest duration and at the lowest dose of medication required to optimally control the pain and/or improve function and quality of life. We addressed this at length in our recommendations.
Q: How did you decide which types of members to put on the Task Force?
A: First of all, the law that created the Task Force specified the membership composition of the Task Force as well as the expertise that members needed to possess. I urge anyone who is interested in this to read section 101(c) of CARA, which pertains to membership.
In a nutshell, the Task Force has 28 members, representing federal and non-federal entities with diverse disciplines and views. Members have significant public- and private-sector experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, veteran health and minority health, as well as other areas of expertise.
Q: Do you expect organized medicine and the federal government to adopt all of the Task Force's recommendations?
A: We are a federal advisory committee, which means our job is to offer advice – in this case, to the Secretary of Health and Human Services, relevant federal agencies, and, ultimately, the American public. We have no rulemaking authority. It was our job to study the situation and to propose updates to best practices and issue recommendations that address gaps or inconsistencies for managing chronic and acute pain.
Q: Dr. Singh, what was your experience like, serving as chair of this task force?
A: It was the honor of a lifetime. I have devoted my career to caring for patients with complex pain issues. Before I agreed to serve as Chief Medical Officer for the Office of the Assistant Secretary of Health, I spent 13 years as a clinical associate professor of anesthesiology, perioperative and pain medicine at Stanford University School of Medicine. I'm board-certified in both anesthesia and pain medicine. So this issue goes to the heart and soul of who I am as a physician and as a person. I have always been committed to the notion of individualized, patient-centered care. And I believe our final report and recommendations value and highlight this important vital principle.
Updated June 3
Q: What were some examples of “best practices” the Task Force recommended?
A: The Task Force recommended the importance of a thorough diagnosis, the establishment of a patient-clinician therapeutic alliance, and a multimodal approach for patients who experience acute injury and perioperative pain, as well as a multidisciplinary approach, when clinically indicated, for patients with chronic painful conditions to improve clinical outcomes while ensuring safer patient care.
The Task Force report also emphasized:
- Innovative research to improve pain treatment options, and
- Using existing resources to mitigate unnecessary opioid exposure, such as National Prescription Drug Take Back Days and the American Association of Poison Control Centers.
The Task Force emphasized safe opioid stewardship by having adequate clinician time and resources to perform a thorough patient history, identify measurable goals, access to multiple treatment modalities, and ensure that patients are part of the treatment decision.
Q: What is needed to deliver patient-centered care?
A: A very important principle of the Task Force final report is the need for individualized patient-centered care when diagnosing and treating acute and chronic pain. Each person has their own unique set of medical, genetic, environmental and sociocultural factors that affect their medical conditions and lives. A biopsychosocial approach is absolutely needed to address each person’s unique challenges and to achieve the best possible clinical outcomes. Clinicians on the front lines treating patients with painful conditions need enough time and resources to perform a thorough history, physical exam and risk assessment when determining a diagnosis and a treatment plan, especially when considering medications such as opioids. Each of these steps is essential for clinicians to form a therapeutic alliance with their patients because the goal of treatment is to improve clinical outcomes. Pain is a primary symptom associated with many chronic conditions such as back and neck pain, lupus, multiple sclerosis, phantom limb pain and others. Chronic pain can be a disease in of itself when it persists beyond healing from an injury or not associated with another disease process. Many different possible medical conditions contribute to significant challenges in obtaining adequate care for chronic pain, resulting in profound physical, emotional and societal costs. In the end, there is no “one size” treatment that fits all.
Q: Which patient safety measures are covered in the report?
A: The report emphasizes safe opioid stewardship through a clear discussion between patients and their clinicians of risks and benefits, consideration of non-opioid alternatives, screening tools such as prescription drug monitoring program checks and lab tests, and clear measureable goals that include improved functionality, quality of life and activities of daily living. These are all essential components of risk assessment. The report emphasizes that when opioids are clinically indicated and prescribed as part of a treatment plan, then the shortest duration of the lowest effective dose is used, along with periodic reassessment. The Task Force report notes that opioid management should be viewed as complex management in medical care and clinicians should be provided time and resources through appropriate payment and reimbursement to ensure they are able to provide the safest and most effective care.
Q: What barriers to adequate pain care are addressed by the Task Force?
Several factors act as barriers to adequate pain care, including stigmatization of patients with pain, insufficient insurance coverage for pain management services, complex opioid management requirements, workforce shortages of medical and behavioral pain management specialists, provider disincentives to treat pain, clinicians’ underestimation of patients’ reports of pain, medication and biological product shortages and the need for more research on innovative and effective pain management approaches. Pain and substance use disorder management is insufficiently covered in medical education and training programs, which has a downstream impact on the extent to which patients are educated about pain and substance use disorders.
The Task Force recommends more effective education about acute and chronic pain at all levels of clinician training with the use of proven innovations, such as the Extension for Community Healthcare Outcomes (Project ECHO) telementoring model. Research is also fundamental to advancing both the understanding and treatment of acute and chronic pain. New knowledge development is needed in various areas of pain research, including molecular and cellular mechanisms of pain, the genetics of pain, bio-behavioral pain and preclinical models of pain. Supporting research initiatives, such as the NIH HEAL Initiative (Helping to End Addiction Long-term), which includes the Acute to Chronic Pain Signatures Program, will aid in addressing current research gaps. As novel and proven treatment options emerge to improve acute pain and specific chronic pain conditions, they should be rapidly incorporated.
Q: Which special populations are highlighted by the Task Force report?
A: Painful conditions and pain management are complex in part because various populations have unique issues that affect acute and chronic pain. Special populations in pain management that the Task Force identified include the following categories and conditions:
- Active duty service members and veterans,
- Older adults,
- Pregnant women,
- Sickle cell disease,
- Chronic relapsing pain conditions,
- Alaska Natives, American Indians, African-Americans, and Hispanic/Latino Americans
- Cancer and those in palliative/hospice care
The special populations section in this report was included to highlight special considerations for pain management. The populations highlighted in the report are not exhaustive, and the special populations section on chronic relapsing conditions is intended to serve as a general category that applies to many painful conditions not specifically mentioned. No special population was purposefully excluded from the report.
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