Saturday, February 24, 2018

AIPM Response to Draft Report from President’s Opioid Commission

U.S._Capitol_BuildingAfter multiple delays, the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its draft report on Monday, July 31st, proposing well over a dozen possible steps that the President could take to address addiction to, and misuse of, opioids.

As a pain management organization focused on the importance of integrative care and treating the whole person, we anxiously await each and every report and piece of guidance from a government entity pertaining to the “opioid epidemic”. Each time we wonder, “Will this be the report that finally addresses the big picture? That recognizes that the only way to truly address overuse of opioids is to improve the current state of pain management options that may be affordably accessed by persons living with pain?”

In June, the Consumer Pain Advocacy Task Force (CPATF), co-facilitated by our very own Amy Goldstein, Director of the State Pain Policy Advocacy Network, sent a letter to this commission on behalf of 73 organizations urging that the commission recognize the inter-relationship of the nation’s chronic pain and opioid epidemics. The letter stated, as we at AIPM have long argued, that “Reducing the supply of opioids will not, by itself, solve this crisis. We must also accelerate access to existing – as well as discover new – evidence-based pharmacologic, nonpharmacologic and integrative chronic pain treatments.”  Specifically, the letter urged that the commission: (1) expand and expedite pain research; (2) transform pain care through implementation of the National Pain Strategy; and (3) surveil the burden of chronic pain through CDC data collection, analysis, and publication.

Did the President’s Commission see the big picture?

The short answer: not entirely, but it seems that they’re trying—and there is still time for improvement since this is a draft report.

The longer answer?

By now, you’ve likely heard the commission’s top recommendation: that a national emergency be declared under either the Public Health Service Act or the Stafford Act. That’s great for a headline, and could potentially affect funding for initiatives, but it doesn’t offer much clarity about real solutions. So, what did the commission actually recommend? Quite a lot.

Related to treating and mitigating abuse and overdose events, the commission had quite a few good recommendations that we fully support:

  • Rapidly increase treatment capacity for substance use disorder.
  • Establish and fund a federal program to enhance access to medication assisted treatment.
  • Provide model legislation for states to allow naloxone dispensing via standing orders.
  • Provide funding and support to states to enhance interstate sharing of prescription monitoring program data.
  • Enforce the Mental Health Parity and Addiction Equity Act to ensure insurance coverage for substance use disorder treatment.
  • Immediately instruct NIH to work with the pharmaceutical industry in the development of additional medication assisted treatment options to treat substance use disorder.

Those solutions are all well and good—and vital—but they really only address one side of the equation. What about reducing the need for opioid medications in the first place, thereby reducing exposures to opioids that can trigger substance use disorders in vulnerable individuals? What about those living with pain conditions who require compassionate health care?

While few and far between, the commission did make a few recommendations pertaining to the treatment of persons with pain:

  • NIH should be instructed to work with the pharmaceutical industry in the development of new, non-opioid pain relievers based on research to clarify the biology of pain.
  • Research initiatives and opportunities should be funded to combat the epidemic and enhance treatment options, including alternative pain management strategies, and treatment for vulnerable populations through work by NIH, HHS, CDC, FDA, SAMHSA, and pharmaceutical experts.
  • Prescriber education initiatives related to pain and opioid prescribing should be mandated within medical schools and also in order to receive DEA registration to prescribe controlled substances. HHS, in coordination with partners, should also consider mandatory continuing medical education for professionals.
  • A detailed analysis of clinical problems encountered in applying recommended prescribing guidelines should be conducted and solutions developed.

We are extremely pleased to see these pain-related recommendations, and we believe each of them is an imperative tool in addressing the dual public health crises of prescription drug abuse and inadequate treatment for pain. However, we remain utterly disappointed at what is still missing.

  • There is very little mention of people with pain. In a report that is essentially about pain medication and its ramifications, there is no mention anywhere of the need to ensure that people living with pain have the same access to high quality health care as any other person in need of health care, nor is there any mention of the need to avoid negative unintended consequences to this population.
  • There is no mention of non-pharmacologic treatments. While we fully support the development of non-opioid pain medications, we also support increased access to, and affordability of, non-pharmacological pain management. Similar to other chronic conditions like diabetes and hypertension, chronic pain isn’t typically cured, but is managed with a combination of therapies and approaches specific to the individual. However, this kind of interdisciplinary integrative pain care is uncommon, in part because services other than traditional allopathic medical care are often poorly reimbursed and in part because these services are often in short supply in rural and other underserved areas.  If we are to optimally treat the 100 million Americans living with pain while reducing the prescription drug overdose epidemic, we must increase access to alternative forms of treatment, including chiropractic care, acupuncture, occupational therapy, and more.
  • There is no mention of the National Pain Strategy (NPS). The NPS is the government’s first interagency strategic plan to implement a system of safe, effective, evidence-based pain care in America. However, since its release in March of 2016, the NPS remains unfunded and HHS has not begun to formally implement the NPS objectives and deliverables across federal agencies. While the NPS contained dozens of recommendations, both short-term and long-term, for improving pain care in America, the commission’s report touches on only one of these recommendations by urging improved pain care education (and even in that, the commission focuses on opioid education rather than teaching balanced pain care).
  • There is no recommendation to surveil the burden of chronic pain. Like the CDC’s extensive efforts to understand and surveil the opioid epidemic, it is critical that the agency begin to study and surveil chronic pain’s prevalence, impact, and treatment over time – overall, for specific chronic pain types, and within specific populations. In addition, national surveillance efforts are needed to evaluate population-level interventions, evaluate the impact of changing public policies, and identify emerging needs. With this information, we can begin to urge insurers to align reimbursement policies so that they prioritize coverage for the safest and most effective pain management options.

Several federal agencies have recognized the urgent need to address unattended chronic pain as part of a comprehensive strategy to curb the opioid epidemic, and along with the broader pain community, have made significant progress in recent years in developing extensive plans and initiatives to advance chronic pain treatment, education, and research. However, support and funding for this vital work is urgently needed from the President and Congress if we are to be successful in mitigating the nation’s intertwined epidemics of opioid abuse and chronic pain.

We sincerely hope that, before releasing their final report, the commission strengthens its recommendations so that those recommendations best support people with pain by improving access to safe and effective balanced pain management, thus avoiding unnecessary exposure to opioids and preventing misuse and addiction before they ever start.

Update, August 10, 2017:
President Donald Trump is officially declaring the opioid crisis a “national emergency.” We are pleased that he is taking this step that was recommended by his opioid commission, and we hope that it results in funding for much needed programs. We caution, however, that there still is no indication that any of the increased funding will be dedicated to increasing access to integrative pain care, leaving us to wonder how effective this effort will be if our above recommendations are not heeded.



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5 responses

  1. Carol
    August 2, 2017 at 7:58 pm

    Katie, thank you for taking your time to study this issue. You are very fair. I am a pain patient, 72 yrs old and have a very upsetting story to share. It too is being ignored but is important. Please let me know if you are interested in hearing this information. I know you must be busy.

    God Bless You

    • Katie Duensing
      August 3, 2017 at 9:29 am

      Carol, thank you for your kind words. I am very sorry to hear that you have an upsetting story. I will email you directly so that we may discuss privately.

  2. Ashley
    August 2, 2017 at 8:41 pm

    As a 10-year Chronic Pain Veteran, dependent on opioids that only allow me the most basic daily physical abilities (such as personal hygiene, picking my child up from school, and completing some household tasks with assistance) I am very hopeful that a solution for chronic pain patients is established.
    To date, I have been to three appointments with my pain management physician (one of the best in my state) where he was forced to tell me that he had to change my prescription for my pain medication because the one I was on had been “Taken off the market.” I live in fear that, sooner rather than later, he is going to tell me that there are no options left.
    At that point I will become a cripple… in a constant state of overwhelmingly severe pain that if not relieved, causes me to have terrible seizures. (Although my seizures are not the “typical tonic-clinic seizures,” I have periods of time from 15 minutes to a few hours, where although I am awake, I cannot remember anything or perform even basic motor skill functions. After the seizure ends, I go into a coma-like state, where I cannot be waked up. I lose bladder and bowel control, and these coma-like states can last anywhere from 2-3 hours up to 36-48 hours.)
    I am literally in so much pain that my brain causes my body to betray me by doing things I cannot control. I do not share these personal details for attention or sympathy, but because many people do not realize how serious chronic pain CAN BE.
    I hope and pray that the millions of TRUE chronic pain patients (NOT the ones just putting on a 15-minute charade of pain in search of narcotic painkillers) have a CHANCE to live our lives with at least SOME pain relief. There is no ETHICAL doctor in the world that will ever prescribe enough pain medication to eradicate 100% of anyone’s pain. But the percentage that we do get is sufficient for some level of daily activity. And that is all we are asking for. We all live with some level of pain every day, in spite of our pain medication, and we would all like to continue to LIVE with chronic pain.

  3. August 15, 2017 at 4:06 pm

    Ms. Duensing, Thank you for such a well written and informative article. As a company that works with pain physicians across over 36 states, the one component we would like to see added to the Opioid Commission plan is the behavioral health aspect co-morbid with so many pain patients. Our physicians using GreenLight to screen their patients for depression, anxiety, and substance abuse history are receiving better outcomes. We hope to continue to support the medical community’s efforts to both provide relief for chronic pain sufferers and to address the risk of addiction. V/r, Jim, VP Greenlight

  4. August 16, 2017 at 10:56 am

    Ms Duensing, your article is indeed informative and thoughtful. But you do not go nearly far enough. The CDC is already indoctrinating physicians in Continuing Medical Education based on the highly flawed 2016 opioid guidelines they published. A physician acquaintance of mine had gone through their materials and found multiple errors and discredited assertions about both chronic pain treatment, and the nature and risks of addiction.

    The CDC guidelines are dangerously biased against opioids, wrong on major details of medical best practice, egregiously incomplete and outright dangerous. These guidelines are forcing doctors out of pain management in droves, and causing pain patients to be denied treatment with the only medications that have been effective for them. People are dying by suicide from unbearable pain as their doctors stand aside in the face of a barrage of misinformation and outright fraudulent hype.

    I call on the US Congress to direct CDC to withdraw the opioid guidelines and their physician CME courses for a major ground-up review and revision. The process this time should be led by board certified pain management physicians in community practice, instead of by financially self-interested addiction therapists or anti-opioid partisans from PROP (Physicians for Responsible Opioid Prescription). It should also incorporate the input of pain patients or advocates as voting members of the writing group.

    Richard A. Lawhern, Ph.D.
    Patient Advocate

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About Katie Duensing, JD, Director of Legislative and Regulatory Affairs