AAPM Responds to CDC Call for Comments on Management of Acute and Chronic Pain

Comments submitted by the American Academy of Pain Medicine to the Centers for Disease Control and Prevention Docket No. CDC-2020-0029 on June 15, 2020. View full comments including references.

The American Academy of Pain Medicine appreciates the opportunity to respond to the Centers for Disease Control and Prevention (CDC) Request for Comment on Management of Acute and Chronic Pain and offer the following pain care priorities:

Opioids for chronic non-cancer pain; appropriate and safe opioid analgesic prescribing for chronic pain

• Acknowledge and emphasize the importance of individualized patient care. Preservation of physician autonomy in clinical decision-making is paramount to the delivery of patient-centered care.
• Reduce regulatory barriers to appropriate opioid prescribing when medically indicated.
• Promote safe prescribing practices including utilization of opioids with lower risk profiles (e.g. buprenorphine).
• Conduct regular opioid use screening and monitoring.
• Implement standardized monitoring and best practices.
• Measure appropriate functional outcomes (e.g. pain disability, pain interference, etc.)
• Highlight conditions treated ineffectively with chronic opioid therapy and where opioids are not recommended (e.g. primary headache disorders, fibromyalgia).

Opioids for acute, post-surgical pain; risks of prolonged opioid prescribing

• Promote evidence-based guidelines and prescribing strategies (lowest amount for shortest duration, co-prescribe naloxone, screen for SUD or risk, PDMP, etc.); maximize non-opioid and non-pharmacologic strategies.
• Promote patient education regarding risks and side effects including withdrawal, dependency and addiction.

Opioid taper indications/strategies

• Utilize and individualize guidelines on how and when to taper opioids.
• Acknowledge heightened patient risk of death from overdose or suicide after stopping opioid treatment.
• Emphasize the importance of concurrent behavioral health and/or opioid or substance use disorder treatment during opioid tapering.
• Recognize the potential harms of forced opioid tapering.

Interdisciplinary pain management best practices 

• Facilitate access to appropriate multidisciplinary and interdisciplinary pain care strategies. Multimodal pain care is required for optimal outcomes. Integrating behavioral pain management strategies into acute and chronic pain care is a national imperative.
• Implement the National Pain Strategy.
• Facilitate national systems for broad integration of multidimensional assessment and multimodal pain care that engages patients as active participants in symptom self-management.
• Individualize pain care (emphasize the imperative of patient-centered care).
• Reduce access barriers and financial barriers to interdisciplinary pain rehabilitation programs that utilize a biopsychosocial model of care. Such programs have demonstrated efficacy in reducing pain, improving function, improving mood, and teaching patients self-management skills. Interdisciplinary programs have clearly demonstrated a successful model for tapering and/or discontinuing opioids, independent of dose and duration of treatment, while improving pain, function, and quality of life for patients.

Barriers for multidisciplinary chronic pain management

• Address, as a priority, the lack of or insufficient insurance reimbursement/coverage versus inadequate access to non-pharmacologic strategies (e.g. acupuncture, chiropractor, nutrition consultation, exercise programs, physical therapy, mental health support, integrative medicine, etc.).
• Prioritize compassionate, effective pain care to decrease wide-spread suffering and provider-driven stigma.
• Recognize social determinants of health and barriers to pain care access.
• Prioritize solutions for additional insurance-based barriers to evidence-based nonpharmacologic pain management interventions: 1) payers and benefit plans continue to lack consistent coverage; 2) prior authorization processes impede access; 3) out-of-pocket expenses can be prohibitive for patients. A number of payers remain focused at times on opioid prescribing limits versus improving access for non-pharmacologic therapies.

Pain management education

• Integrate interprofessional pain management competencies as well as substance use disorder prevention, screening, and treatment competencies into medical, nursing, dental, etc., pre-licensure and continuing medical education.
• Transform psychology education and training to include and emphasize pain management.

Pain care measurement and monitoring strategies 

• Utilize appropriate measures to adequately monitor patient function, pain interference, quality of life, disability, etc.
• Promote responsible use of and interpretation of urine drug screen monitoring.

Substance use disorder (SUD) screening, prevention and treatment; co-managing pain and SUD

• Normalize substance use disorders as a treatable / preventable disease.
• Prioritize substance use disorder treatment and prevention as a public health priority.
• Reduce the stigmatization of substance use disorder treatment.
• Understand the role of buprenorphine in treating pain and opioid use disorder (OUD).
• Individualize acute pain treatment plans in patients with OUD.

Mental health care access 

• Ensure adequate access to mental health providers and behavioral medicine for patients with chronic pain.
• Prioritize mental health care modalities that are low-cost and low-burden to improve access and compliance to mental health care.
• Emphasize brief and effective behavioral health modalities, such as single-session pain classes.
• Expand access to patient education that highlights the effectiveness of both brief and long-term access to behavioral pain treatment.

Pain management research and funding

• Prioritize adequate funding and support pain management studies and research for new pharmacologic and non- pharmacologic pain care targets and strategies.