HHS Report on Pain Mgmt Best Practices – part 3

Draft Report on Pain Management Best Practices | HHS.gov – Dec 2018

This document is so long and so detailed that I spent hours working it over to add my own voluminous commentary.

I posted the second, most significant part yesterday, HHS Report on Pain Mgmt Best Practices – part 2, and the first part the day before: HHS Report on Pain Mgmt Best Practices – part 1.  

This is the third and final part of my series, and covers the middle of the document, starting where I left off in the second part detailing interventional procedures.

Facet joint nerve block and denervation injection are common fluoroscopy-guided procedures for facet-related spinal pain of the low back and neck area in which local anesthesia with or without steroids is injected onto the medial branch nerves that supply these joints (medial branch blocks or less commonly directly into the facet joint). These injections are primarily diagnostic but can also be therapeutic, providing long-term relief.

Cryoneuroablation is a specialized interventional pain management technique that uses a cryoprobe to freeze sensory nerves at the source of pain to provide long-term pain relief.

RF Ablation. Conventional RF lesioning and pulse RF (PRF) are both means to ablate certain nerves that have been identified as contributing to chronic pain syndromes, and they continue to have great value as a treatment modality in the management of a variety of pain syndromes. Furthermore, studies have shown conventional RF provides benefits in appropriate patients.

Peripheral nerve injections, commonly referred to as peripheral nerve blocks (PNBs), are injections of local anesthesia frequently mixed with anti-inflammatory steroid medication or clonidine for both diagnostic and therapeutic pain relief purposes

Similar to PNBs, sympathetic nerve blocks (SNBs) — injections of local anesthesia at the sympathetic nerve chain — can be used to diagnose or treat pain that involves the sympathetic nervous system

Neuromodulation techniques use device-based electrical or magnetic stimulation to activate central or peripheral nervous system tissue associated with pain pathways to produce analgesia or reduce sensitivity to pain. This is an area of growth and innovation for chronic pain treatment, including neuropathic pain, and for both the central and peripheral nervous system.

I don’t doubt that this “is an area of growth and innovation” because there are big profits to be made from such devices.

Spinal cord stimulation using a variety of waveforms and frequencies and dorsal root ganglion stimulation, collectively, have five level-1 studies demonstrating their efficacy in low-back and lower extremity pain.

They are overlooking the iatrogenic danger of implanting such devices and the increasing reports of additional pain and even damage.

Intrathecal Pain Pumps. Because there are opioid receptors on the spinal cord and at specific areas of the brain, small doses of opioids in the spinal fluid can provide significant analgesia at much lower doses than oral opioids. Implanted intrathecal pumps with catheters in the spinal fluid can supply medication continuously, and they have been used for cancer as well as noncancer pain.

Vertebral augmentation stabilizes the spine through the application of cement to vertebral compression fractures that are painful and refractory to medical treatment228; this approach can include vertebroplasty (injecting cement into a fractured vertebra) or balloon kyphoplasty (using an inflatable balloon to create injection space). Evidence suggests that balloon-assisted kyphoplasty is one of the most effective vertebral augmentation procedures.

Trigger points are palpable, tense bands of skeletal muscle fibers that, upon compression, are capable of producing both local and referred pain.

Using either dry needling or injections of local anesthesia, trigger points can be disrupted, resulting in relaxation and lengthening of the muscle fiber, thereby providing pain relief.

These methods have not been carefully studied and proven effective.

Other types of direct injections include intramuscular, intrabursal, and intra-articular injections for muscle pain, bursitis, and joint pain, respectively.

Joint Injections. In addition to the facet joints, corticosteroid injections into other joints (e.g., shoulder, elbow, wrist, knee, ankle) are common interventional procedures, particularly in the treatment of inflammatory arthritis and basal joint arthritis

There have been thousands of reports of damage from injections that missed their mark.

They are so common and done right in the office, so doctors have perhaps gotten careless and do these injections without the proper imaging to verify the needle’s location. Since we are all built slightly (or greatly) different, we can be seriously damaged by doctors who “just wing it”.

Interspinous Process Spacer Devices. Research has shown that interspinous process spacer devices can provide relief for patients with lumbar spinal stenosis with neuroclaudication.

Regenerative/adult autologous stem cell therapy may show promise in the treatment of multiple painful conditions.

Gaps and Recommendations

Gap 3: There is a trend of inadequately trained physicians and non-physicians performing interventional procedures. This trend can potentially lead to serious complications and inappropriate utilization. For example, outside the Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs, there is currently little to no oversight over training requirements for interventional procedures.

This is exactly what I’ve been warning about too, so I’m glad the task force is aware of these dangers.

2.4.1 Perioperative Management of Chronic Pain Patients

Patients on long-term opioid therapy can be more complicated to manage in the perioperative period compared with patients who are opioid naive.

Many doctors will try to tell a chronic pain patient that they must come off all their opioids before surgery. THIS IS NOT TRUE:

Chronic pain patients whose pain is managed by a clinician should have their pain management specialist consulted and involved in the planning of their pain control during and after the perioperative process.

Gaps and Recommendations

Gap 1: Chronic pain patients undergoing a surgical procedure often have complex issues that go unaddressed that may lead to incomplete and poor care.

2.5 Behavioral Health Approaches

Chronic pain patients are at increased risk for psychological distress, maladaptive coping, and physical inactivity related to fear of reinjury.

Individuals with chronic pain are more likely to have disabilities than patients with other chronic health conditions, such as stroke, kidney failure, cancer, diabetes, and heart disease.

High-impact chronic pain is especially disruptive to multiple aspects of patients’ life, including their relationships, work, physical activity, sleep, self-care, and self-esteem.

It’s good to see the full burden of life with chronic pain spelled out so clearly.

Behavioral health approaches as part of pain management are to be considered as a key component of the biopsychosocial model and multidisciplinary pain management. These approaches aim to improve the overall pain experience and restore function by addressing the cognitive, emotional, behavioral, and social factors that contribute to pain-related stress and impairment.

I absolutely agree with the need for psychological counseling as an additional help, but not as a replacement for other pain management treatments to address the physical issues contributing to pain.

The following paragraphs briefly describe behavioral health approaches, which can be considered singularly or as part of a multimodal approach to the management of chronic and acute pain, depending on the patient and their medical conditions.

Behavioral therapy (BT) for pain treatment focuses largely on applying the principles of operant conditioning to identify and reduce maladaptive pain behaviors (e.g., fear avoidance) and increase adaptive or “well” behaviors.

This improvement is achieved by

  • minimizing reinforcement of maladaptive behaviors,
  • providing reinforcement of well behaviors, and
  • reducing avoidance behaviors through gradual exposure to the fear-provoking stimuli (e.g., exercise).

The overall goal of BT in the treatment of pain is to increase function despite pain

Cognitive behavioral therapy (CBT) aims to reduce maladaptive behavior and improve overall functioning. However, in addition to focusing on altering behavioral responses to pain, CBT focuses on shifting cognitions and improving pain coping skills.

CBT includes psychoeducation about the relationship between psychological factors (e.g., thoughts, feelings) and pain; cognitive restructuring of maladaptive thought patterns; and training in a variety of pain coping strategies, including activity pacing and pleasant activity scheduling.

Acceptance and commitment therapy (ACT) is a form of CBT that emphasizes

  1. observing and accepting thoughts and feelings,
  2. living in the present moment, and
  3. behaving in a manner that serves an individual’s chosen values.

Unlike traditional CBT approaches, ACT focuses on creating psychological flexibility through acceptance of psychological and physical experiences rather than by challenging them.

Mindfulness-based stress reduction (MBSR) is a mind-body treatment developed by Jon Kabat-Zinn typically delivered in a group format that focuses on improving patients’ awareness and acceptance of their physical and psychological experiences through intensive training in mindfulness meditation.

Mindfulness meditation teaches patients to self-regulate their pain and pain-related comorbidities by developing nonjudgmental awareness and acceptance of present moment sensations, emotions, and thoughts.

I take offense at the universal belief that stress and muscular tension cause pain.

With EDS, I have to hold my body tight all the time to prevent my joints from moving out of position. A relaxing massage makes a total mess of my skeletal integrity, which causes sharp pain when I get up afterward.

Emotional awareness and expression therapy (EAET) is an emotion-focused therapy for patients with a history of trauma or psychosocial adversity who suffer from centralized pain conditions.

Oh, give me a break! I’ve lived with constant pain since I was a kid (due to the genetic defect of EDS). That’s my trauma.

In this approach, patients are taught to understand that their pain is exacerbated or maintained by unresolved emotional experiences that influence neural pathways involved in pain.

This is so condescending to patients who have all kinds of very physical causes for their pain.

Patients are taught to become aware of these unresolved experiences, which include suppressed or avoided trauma, adversity, and conflict, and to adaptively express their emotions related to these experiences.

I’d like to express my emotion of outrage and disgust that the task force allowed this woo-woo nonsense into this report.

Patients learn that control over pain can be achieved through emotional awareness and expression.

This is an outrageous claim. The vast majority of pain patients know darn well that we cannot “control our pain” and to claim this is possible is an accusation that we’re just not emotionally aware enough to control our pain.

Self-regulatory or psychophysiological approaches include treatments such as biofeedback, relaxation training, and hypnotherapy. These approaches use the mind-body connection to help patients with pain develop control over their physiologic and psychological responses to pain.

Getting reimbursed by insurance for any of these approaches is impossible.

Behavioral health interventions can be effective in improving clinical outcomes for pain but treatment should be tailored to address patient preferences and needs.

This tailoring requires careful assessment of patients’ pain perceptions, cognitive and emotional responses, coping skills, and social and environmental status. It also requires accurate diagnosis of comorbid psychosocial concerns.

2.5.1 Access to Psychological Interventions

Despite widespread understanding of the importance of psychological interventions in the management of pain, many patients with pain receive inadequate care.

Many factors contribute to the problem of inadequate care for pain, including

  • clinical barriers (e.g., treatment accessibility, knowledge gaps, provider attitudes),
  • health care system-related barriers (e.g., cost and reimbursement issues), and
  • patient-related barriers (e.g., stigma, attitudinal variables).

As noted in other sections of this report, the lack of health care insurance coverage for psychological services has also been cited as a significant barrier to adequate pain management.

Yet, no one is taking any action on this.

Insurance companies are encouraged to restrict coverage of opioids, but they are never encouraged to provide better coverage for non-opioid pain treatments.

Both a need for trained pain psychologists and appropriate incentives are required to fill the work gap. Although several organizations have identified policy recommendations to close gaps in access to pain management services, coverage barriers persist.

Yes, and they will until the authorities finally stop just talking about them but actually do something to make them financially feasilble for all those patients they have taken off opioids with nothing else to fill the gap.

2.5.2 Chronic Pain Patients With Mental Health and Substance Use Comorbidities

It is established that psychosocial distress can contribute to pain intensity, pain-related disability, and poor response to chronic pain treatment.

Untreated psychiatric conditions and current or historical SUD also increase the risk of both unintentional and intentional medication mismanagement, OUD, and overdose.

Given the intersection between psychiatric/psychological symptoms and chronic pain, it is important that the behavioral health needs of patients with pain are appropriately and carefully evaluated and treated with the concurrent physical pain problem.

2.6 Complementary and Integrative Health

Complementary and integrative health approaches for the treatment or management of pain conditions consist of a wide variety of interventions, including mind-body behavioral interventions, acupuncture and massage, osteopathic and chiropractic manipulation, meditative movement therapies (e.g., yoga, tai chi), and natural products, among others.

The National Institutes of Health (NIH) National Center for Complementary and Integrative Health defines

  • “complementary approaches” as those nonmainstream practices that are used together with traditional medicine, and defines
  • “alternative approaches” as those used in place of conventional medicine,

noting that most patients who use nonmainstream approaches do so with conventional treatments.

There are many definitions of “integrative” health care, but all involve bringing conventional approaches, as well as complementary and integrative health approaches together in a coordinated way.

2.7.5 Chronic Relapsing Pain Conditions

Chronic pain in pediatric and adult populations with periods of remission and frequent relapses defines “chronic relapsing pain conditions.”

Examples of such conditions include various

  • degenerative,
  • inflammatory,
  • immune-mediated,
  • rheumatologic, and
  • neurologic conditions

such as

  • MS,
  • various cancer syndromes,
  • trigeminal neuralgia,
  • lupus,
  • Parkinson’s disease,
  • postherpetic neuralgia,
  • CRPS,
  • porphyria,
  • systemic lupus erythematosus,
  • lumbar radicular pain,
  • migraines, and
  • cluster headaches.

Acute pain flares on top of the chronic pain condition can be a common occurrence that may affect daily routines and overall functionality, resulting in additional morbidity and the need for comprehensive pain care.

=====

Below is an outline of the whole report with links to individual sections:

1.      Introduction
 2.    Clinical Best Practices
2.1    Approaches to Pain Management
2.1.1 Acute Pain
2.2    Medication
2.2.1 Risk Assessment
2.2.2 Overdose Prevention Education and Naloxone
2.3    Restorative Therapies
2.4    Interventional Procedures
2.4.1 Perioperative Management of Chronic Pain Patients
2.5    Behavioral Health Approaches
2.5.1 Access to Psychological Interventions
2.5.2 Chronic Pain Patients With Mental Health and Substance Use Comorbidities
2.6    Complementary and Integrative Health
2.7    Special Populations
2.7.1 Unique Issues Related to Pediatric Pain Management
2.7.2 Older Adults
2.7.3 Unique Issues Related to Pain Management in Women
2.7.4 Pregnancy
2.7.5 Chronic Relapsing Pain Conditions
2.7.6 Sickle Cell Disease
2.7.7 Health Disparities in Racial and Ethnic Populations, Including African-Americans, Latinos, American Indians, and Alaska Natives
2.7.8 Military Personnel and Veterans
3.    Cross-Cutting Clinical and Policy Best Practices
3.1    Stigma
3.2    Education
3.2.1 Public Education
3.2.2 Patient Education
3.2.3 Provider Education
3.3    Access to Pain Care
3.3.1 Medication Shortage
3.3.2 Insurance Coverage for Complex Management Situations
3.3.3 Workforce
3.3.4 Research
  4.    Review of the CDC Guideline
Acronyms
References

7 thoughts on “HHS Report on Pain Mgmt Best Practices – part 3

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