Response to Surgeon General’s Opioid Pledge

Pain Academy’s Response to Surgeon General’s Opioid Pledge: “Come to terms with chronic pain” – National Pain Report – September 30, 2016 by Ed Coghlan

Since the CDC Guideline on Opioid Prescribing was released what has rankled many in the pain community—doctors, patients and advocacy organizations alike – was the lack of options to opioid prescribing.

The Academy of Integrative Pain Management added its voice this week in criticizing the Surgeon General’s Opioid Pledge.  It coincides with an op-ed published in USA Today from AIPM’s immediate past president, Dr. Robert Bonakdar.

In the USA TODAY, Dr. Bonakdar wrote, while over-prescribing of opioids and lack of insurance coverage for non-pharmacological treatments are problems, what the Surgeon General really needs to address is more fundamental – in the US, we have difficulty dealing with chronic pain.  

“Chronic pain is a complex scenario that not only affects the back or shoulder, but one that over time can shrink the brain while creating or worsening fatigue, insomnia, depression, anxiety, obesity and risk of suicide.  The pain transformation called for by the IOM and most recently the National Pain Strategy requires not just a campaign, but an integrative, patient-centered approach to support someone whose entire existence is affected.”

In addition, it is the only organization with three staff working full time on policy and advocacy at the federal, state, and local level to assure patients have access to integrative care that is paid for by insurance companies.  

Here is the article referred to above:

Docs need help to ease opioid epidemic: Column – Robert Bonakdar – September 28, 2016

In an unprecedented move, Surgeon General Vivek Murthy sent a letter to every doctor in America last month. It did not congratulate us on a job well done; instead, it said we need an urgent change in how we manage pain and opioids. The gesture, launching the TurnTheTideRx campaign, was praiseworthy but unfortunately misses the point.

“I have seen opioids rise from being important medicines used judiciously, to being among the most widely prescribed class of pain medications. I have seen doctors and drug companies blamed for the epidemic, the FDA slap drug companies for improper claims and insurance companies who bought the line provide coverage that fueled a 300% increase in prescriptions since 1999 (with similar skyrocketing of pain procedures and surgeries).”

At the same time, many well-established non-pharmacologic treatments like biofeedback and cognitive behavioral therapy (CBT), endorsed in Murthy’s resource guide, are routinely denied by insurance companies.

As the new campaign corroborates, this shift to opioids for pain care has not created any significant improvement in pain and disability.

This is because we have taken an acute care model and repurposed it as a poor standard for chronic pain care in America.

This is what the Institute of Medicine (IOM) pain report noted in 2011 — that “all too often treatment is delayed, disorganized, inaccessible, or ineffective.”

The institute recommended that we “increasingly aim at tailoring pain care to each person’s experience, and self-management of pain should be promoted.”

Even with strong statements like this, I have not had any sales reps trying to sell me on tai chi, yoga or mindfulness or a prior authorization form asking me if I had considered biofeedback instead of a new medication. These treatments don’t have any overuse epidemics or commercials telling you to ask your doctor if they are right for you.

What I hoped Murthy would discuss is the difficulty America has dealing with chronic pain.

As the root word for pain
— peine for punishment or agony — implies,
it is not just a number.

Chronic pain is a complex scenario that not only affects the back or shoulder, but one that over time can shrink the brain while creating or worsening fatigue, insomnia, depression, anxiety, obesity and risk of suicide.

The pain transformation called for by the IOM and most recently the National Pain Strategy requires not just a campaign, but an integrative, patient-centered approach to support someone whose entire existence is affected.

Slowly we are realizing this. After focus groups with chronic pain patients found that “fix-it” strategies were failing while also bankrupting the state, Rhode Island created the Ease the Pain Program, which uses case management and treatments like acupuncture, massage and manipulation.

Similarly, starting this year, the Oregon state insurance program will cover acupuncture, CBT and more, based on findings that “lack of support for and knowledge of biopsychosocial pain self-management treatments are serious public health problems.”

100 million Americans with chronic pain, and those that care for them, are being punished by having to deal with opioid restrictions while being denied the treatments that have the most chance of helping them.  

Author: Robert Bonakdar, MD, is Director of Pain Management at the Scripps Center for Integrative Medicine, immediate past president of the Academy of Integrative Pain Management and co-author of the 2016 book Integrative Pain Management. Follow him on Twitter @DrB_Well.

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