Sunday, February 25, 2018

U.S. Surgeon General’s Letter to Prescribers: What’s Missing From This Puzzle?


Some people find working jigsaw puzzles to be a great way to spend their quiet time. Many of us who have done this recognize the frustration felt when, after finding the right places for the first 499 pieces, the 500th piece turns up missing! That sense of frustration and incompleteness is what I’ve been feeling in the wake of a recent letter from the U.S. Surgeon General to all prescribers in the US.

On August 25th, US Surgeon General, Dr. Vivek Murthy, took the unprecedented step of writing all 2.3 million prescribers in the United States, asking them to sign a pledge to change their ways when prescribing opioid analgesics. Specifically, the letter requests that prescribers: 1) educate themselves about safe and effective pain treatment, citing the CDC Opioid Prescribing Guideline; 2) screen patients for opioid use disorder and see that evidence-based treatment is provided when needed; and 3) talk about, and treat, addiction as a chronic illness, not a moral failing.

We can all agree that more education, better screening, and approaching addiction as a medical condition are good things. Opposing those would be like opposing motherhood and apple pie, and I sincerely hope that every prescriber will take this advice to heart. The challenge is that, while we have here three pieces of a puzzle, there is an important fourth piece that is missing.

Conspicuously absent from this initiative is any mention of pain treatments that are alternatives to opioids. Dr. Murthy’s letter drives home the message that health care providers must stop prescribing so much opioid medication in order to minimize opioid abuse, addiction, and overdose. One can argue about whether or not this will be an effective intervention, but the inescapable fact is that a piece of the puzzle is missing: What are clinicians to do if they don’t prescribe opioids?

Every behavioral health specialist worth his or her salt will say that a cardinal rule is this: Never take something away without giving providing a replacement. The Surgeon General is proposing that we take away opioid prescribing, without carefully specifying that doing so for someone who is benefiting from opioid therapy could be harmful, not helpful. My question for Dr. Murthy is: Why isn’t there anything here about the use of non-opioid treatments for pain? Where is the support for the integrative approach to pain care that the CDC guideline recommends, and that we all know is the only safe and sane way to treat pain?

The Missing Piece Found?
Just as I was despairing and once again throwing up my hands in frustration, another government agency rode to the rescue. On September 1, the National Center for Complementary and Integrative Health (NCCIH) issued a report summarizing current scientific evidence for complementary health approaches for chronic pain. This report suggests that some complementary health approaches can help patients manage some types of chronic pain.

Couple this with a report from the Army Surgeon General’s Pain Management Task Force, which recommends that six key non-pharmacologic treatments (acupuncture, yoga, chiropractic/osteopathic manipulation, massage therapy, biofeedback, and mind-body therapies; see table below) be made available to every current and former service member with chronic pain, and you have some pretty good recommendations. These treatments are the missing piece of the puzzle because they can replace some portion of opioid therapy, minimizing both exposure that could lead to an opioid use disorder and excessive prescribing that leaves behind unused opioids for misuse, abuse, or diversion.

Screen Shot 2016-09-02 at 8.25.58 AM
Now we know what the missing piece looks like, but why is it missing? There are a number of reasons, including inadequate education for “traditional” clinicians about these techniques and their uses; a shortage of clinicians providing these treatments, especially in rural and other under-served areas; and reimbursement that is often absent, and frequently inadequate when it is present. For instance, of the six modalities mentioned by the Task Force, Medicare covers only a few types of chiropractic and osteopathic manipulations, and then only for some diagnoses. It covers none of the rest, unless those mind-body therapies are taught in the course of psychotherapy.

Addressing prescription opioid abuse is a complicated and arduous task, requiring multiple approaches. While the government is stepping up, as evidenced by Dr. Murthy’s letter, we need to keep pointing to the missing piece that is support for integrative pain care, and demanding help to find and install that piece. That has been, and continues to be, the primary focus of the Academy’s policy advocacy efforts.

9 responses

  1. September 2, 2016 at 12:41 pm

    Also missing from this puzzle are:
    Nutritional Therapies-Specifically anti-inflammatory diet
    IVs, Infusion, Injections: Myers Cocktails, B-12 etc
    PT and Exercise

  2. Janice Reynolds
    September 3, 2016 at 9:54 pm

    “educate themselves about safe and effective pain treatment”; I do realize he was only talking about opioids however NSAIDs are not being appropriately mentioned, in fact the CDC and others are pushing them to be used instead. First of all for many they would be ineffective because they do not (at least the OTC version) work for severe pain so it is likely people would take too much in order to have some relief and overdose. But the bigger issue is should they even be suggested or prescribed. The Beers Criteria has long had NSAIDs on the list as not being appropriate for older adults and the American Geriatric Society’s Pharmaceutical Interventions for Persistent Pain in the Older Adult agrees. Ibuprofen has long been Black Boxed for Myocardial Infarctions and Stokes as well as GI Bleeds. The least of side effects is long and includes kidney failure and heart failure. I was lucky, I would take an occasional ibuprofen for headache or back pain =my pain plan already included opioids and acetaminophen-when the labs I had done regularly for my anti-seizure medication showed I was going into renal failure. We caught it before any real damage was done, however how many people get regular CMETPs? OTC ibuprofen doesn’t include any of the black boxed warnings except GI bleeds and none of the other scary and common side effects. So if we are talking about safety.. I had a colleague when we were discussing this, say “If I write a prescription for an NSAID and the person dies, nothing will happen. If I write one for n opioid and the person dies, I’ll be investigated. something is wrong here.
    I am glad you mentioned non reimbursement or non-availability for non-pharma interventions because this is a huge issue and some providers don’t quite get it-I had a different colleague say “They [the patients] don’t know how to prioritize” in other words they should be able to pay for it.
    Some non-opioid meds are also not covered. Lidoderm patches have been shown to work well for many with back pain. The VA refuses to prescribe them as do some others. Little side effects and potential for big help and no.

  3. Martin Bates
    September 13, 2016 at 11:32 am

    Amen to your article. All practitioners mentioned see pain patients everyday and get improvements to patients/clients health and ADLs. Imagine what reducing opioid addiction or side effects by just 10 or 20% would mean to the health of our nation.

  4. Debbie Gunter FNP
    September 13, 2016 at 1:06 pm

    I absolutely agree with non-opioid interventions. Patients need to have them not only available, but have insurance coverage for them. For many unfortunate patients, these are not an option because they are not covered expenses! So again, if we say to cut back on prescribing medications, but there is no financial coverage for the other modalities, we again, have a large missing piece of the puzzle.

    Thank you

  5. Kenneth Lister M.D.
    September 13, 2016 at 3:12 pm

    There is another “leg of the stool” that wasn’t mentioned. Integrative pain management requires 3 legs to the stool or it will fall. In addition to pharmacologic and alternative pain therapy, invasive pain management including injections, neuro – ablation and surgery are often required. Only in the larger pain centers are all three legs present. Opiod pain management is still the most lucrative practice.

  6. September 14, 2016 at 4:13 am

    Thank you for an alternative view to the Surgeon General’s suggestions on opioid reduction.

    The only omission from your suggestions are alternative all-natural pain medicines.

    I appreciate mainstream medicine looks askance at treatments not approved, but legal, by the FDA.

    With 80% of nociceptors located in the fifth layer of skin, it’s not surprising pain relief is enjoyed for many nerve and musculoskeletal pain situations using topical solutions.

    While not cures, many get exceptional pain relief sometimes meeting and exceeding pharmacological medications … and usually with no side effects.

  7. Kari Hendra
    September 14, 2016 at 11:40 am

    The insurers and LACK of coverage for complimentary alternatives is the elephant in the room!

  8. Mandi Wagener
    September 15, 2016 at 1:50 am

    I told him/her what I thought. Told them that they were were making my life miserable….

  9. October 20, 2016 at 12:51 pm

    My sentiments exactly. Common sense will only prevail when the CDC assures the alternatives to pain care will be available to all people in all places. Integrating integrative healthcare, allowing the neuroplasticity of the brain to do its work effectively should be a right. Until our care providers can be reimbursed for these services, and patients insurance will cover things like therapeutic massage and acupuncture, will we be able give comprehensive pain care. Thank you, Bob, for backing up words with evidence and holding the moth to the flame.

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About Bob Twillman, PhD, Executive Director of The American Academy of Pain Management