The HHS Pain Management Best Practice Inter-Agency Task Force Report Calls for Patient-Centered and Individualized Care – Jianguo Cheng, MD, PhD, FIPP, Molly Rutherford, MD, MPH, FASAM, Vanila M Singh, MD, MACM – January 2020
At least these folks see the reality: for pain, both acute and chronic, standard treatment with standard doses of standard medications is simply not medically appropriate. Pain treatment is not suitable for standardization.
Some healthcare services must be personalized to be effective, even when they become much more complicated and difficult (meaning, expensive).
The same people insisting on standard dose limits for opioids wouldn’t think of suggesting standard dose limits for blood thinners or insulin or cancer treatments.
The Pain Management Best Practices Inter-Agency Task Force (Task Force) was convened by the US Department of Health and Human Services (HHS), in conjunction with the Department of Defense, the Department of Veterans Affairs, and the Office of National Drug Control Policy.
It was mandated by Congress in the Comprehensive Addiction and Recovery Act (P.L. 114–198) to review best practices for pain management and make recommendations on addressing gaps and inconsistencies.
The Task Force was convened in the midst of the opioid crisis, one of the greatest public health challenges of our time. The Task Force is composed of 29 members representing federal agencies as well as nonfederal experts from a broad range of stakeholders (Figure 1).
After a year of intensive and collaborative work, the Task Force submitted its report to the US Congress on May 30, 2019 .
The report addresses some of the most critical aspects of pain management and includes specific recommendations on how to close the gaps/inconsistencies and advance pain care in the United States. The main takeaways are:
The Task Force Emphasizes Patient-Centered and Individualized Pain Care
The Task Force recognizes the diversity and complexity of pain conditions and highlights the need to address patients’ comorbidities.
Individualized care begins with a thorough assessment and accurate diagnosis of the underlying cause of pain in each patient.
Differentiating various causes of pain helps serve each patient’s unique needs.
Although most uncomplicated cases can be managed appropriately by primary care physicians (PCPs), collaboration among PCPs and pain specialists and their teams is often required to optimally manage complicated cases.
Coordinated care is often required to maximize the therapeutic benefits while minimizing and mitigating potential adverse effects. A collaborative patient–clinician alliance, the cornerstone of best practices, has been eroded in our health care system.
Reforms are needed to
- reduce administrative burden,
- increase face-to-face time with patients, and
- restore the patient–clinician relationship.
I wonder if that last point is even possible because we’ve been so disillusioned about “health care providers”.
We’ve seen doctors turn away patients desperate for their help with unending pain, others have pain relief reduced significantly without any medical reason, and we’ve been lied to when doctors tell us how “dangerous” opioids are without ever mentioning the damage that arises from pain left untreated.
Doctors are clearly not on our side; they cannot be.
In our profiteering medical industry, they are as much victim as perpetrator. The “corporatization” of health care has made us adversaries.
In this system created by and for mainly financial interests, the effort required to fight through all the obstacles to give patients the time and attention and non-standard interventions they might need may not be worth the fight.
State-of-the-Art of Pain Management Strategies and Methodologies
Acute pain can be caused by a variety of different conditions such as trauma and surgery.
A multimodal approach that includes medications, nerve blocks, physical/occupational therapies, and psychological counseling should be considered when indicated for acute pain conditions in order to minimize unnecessary opioid exposure and improve clinical outcomes.
Chronic pain often requires a multidisciplinary approach. Restorative therapies include self-management, behavioral modifications, physiotherapy, therapeutic exercise, and other movement modalities.
Pharmacotherapies should be based on
- the diagnosis and mechanisms of pain,
- relevant comorbidities, and
- a favorable risk–benefit assessment.
- Interventional approaches can be used for diagnostic and therapeutic purposes.
Procedures such as nerve blocks, radiofrequency ablation, and neuromodulation should be performed by well-trained and competent professionals to maximize the therapeutic benefits and minimize potential risks.
Behavioral health approaches that address the psychological, cognitive, emotional, behavioral, and social aspects of pain can improve outcomes in patients with pain and behavioral comorbidities.
Complementary and integrative health approaches, such as acupuncture, massage, and movement therapies (e.g., yoga, tai chi), can be beneficial for certain pain conditions. […and certain individuals]
Health care providers should employ a biopsychosocial and multidisciplinary approach to pain management and consider the distinctive needs of special populations, such as patients with cancer, children, the elderly, and pregnant women, who are confronted with unique challenges associated with pain.
Access to Care
The Task Force identified significant barriers to best practices for patient-centered and individualized care, including workforce shortages, medication shortages, inadequate insurance coverage for complex management situations, and stigma around chronic pain and SUDs.
Stigma is a challenge for patients, families, and providers alike and remains a major barrier to care encountered by patients. The Task Force emphasizes that chronic pain and SUD are medical conditions and each should be treated as such, with compassion, empathy, and expertise.
No matter what “they” say, patients with chronic pain are being treated like insensate slabs of meat and forced to adhere to some arbitrary “standard” guideline protocol designed for the “average American” (a healthy one), not a real patient struggling with pain.
Education of Health Care Providers, Patients, and the Public
Education for the public, including policy-makers and legislators, is emphasized by the Task Force to ensure that the state-of-the-art of pain medicine is considered in the policy-making process, which can profoundly affect patient care and outcomes
I worry about this because most of the “state of the art” information on opioids is actually PROPaganda.
Innovation and Research
The Task Force encourages sustained funding to build pain research capabilities,
- to better understand the mechanisms underlying the transition from acute to chronic pain,
- to translate promising findings into effective diagnostic, preventive, and therapeutic strategies, and
- to implement these strategies effectively in health systems.
Review of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain
he Task Force recognized the guideline’s contributions to mitigating unnecessary opioid exposure. It also recognized unintended consequences, such as forced opioid tapers and patient abandonment, which are due in part to misapplication or misinterpretation of the guideline by various decision-makers.
The CDC recognizes this harm and states that “policies invoking the opioid-prescribing guideline that do not actually reflect its content and nuances can be used to justify actions contrary to the guideline’s intent” . The US Food and Drug Administration also issued a statement regarding harm reduction and patient abandonment. Educating stakeholders about the intent of the guideline and ensuring its appropriate interpretation and application are essential to optimizing patient care.
In summary, the final report, lauded by more than 150 medical organizations, provides a timely framework to strengthen best practices by identifying and bridging gaps in pain care through increasing collaboration, reducing administrative burden, improving access to care, addressing stigma, and enhancing education, innovation, and research. It has never been more urgent to bring together the medical community to work in concert for patient-centered pain care.
Jianguo Cheng, MD, PhD, FIPP
Cleveland Clinic Multidisciplinary Pain Medicine Fellowship Program, Departments of Pain Management and Neurosciences, Cleveland Clinic, Cleveland, Ohio
Molly Rutherford, MD, MPH, FASAM
Family Wellness, PLLC, Crestwood, Kentuck
Vanila M Singh, MD, MACM
Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC, USA