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Guidelines for Expert Witness Qualifications and Testimony

Guidelines for Expert Witness Qualifications and Testimony

A statement by the American Academy of Pain Medicine

Preamble

The integrity of the litigation process in the United States depends in part on the honest, unbiased, responsible testimony of expert witnesses. Parties to litigation frequently call on Pain Medicine physicians as experts to testify regarding medical diagnoses, prognoses, and treatments. Pain Medicine physicians who serve as experts in litigation should do so only within the boundaries of their training, expertise, and professional experience. The American Academy of Pain Medicine (AAPM) supports the concept that expert testimony by qualified Pain Medicine physicians should be objective and unbiased. To limit uninformed and possibly misleading testimony, experts in pain medicine should be qualified for their role and should follow a clear and consistent set of ethical guidelines.

The AAPM offers these guidelines to assist Pain Medicine physicians who are asked to serve as expert witnesses, to attorneys who are considering the engagement of such physicians, and to courts that are called upon to evaluate the qualifications of such witnesses. Not intended to address specific peculiarities of various levels of legal issues addressed in different types of courts, these general guidelines aim to promote transparent and ethical expert witness testimony in legal proceedings.

A. Expert Witness Qualifications

  1. A physician who testifies as an expert witness in pain medicine should have a current, valid, and unrestricted license to practice medicine.
  2. The physician should be Board certified in Pain Medicine through the American Board of Pain Medicine or another Board recognized by the American Board of Medical Specialties.
  3. The physician should have significant clinical experience in the practice of Pain Medicine.
  4. The physician should disclose any conflicts of interest at the beginning of the process in accordance with sound ethical principles.

B. Expert Witness Ethical Guidelines

  1. The review of the medical facts by an expert witness in Pain Medicine should be thorough and impartial. It should not exclude any relevant information. The testimony of the expert witness should be truthful and impartial.
  2. The physician’s testimony should reflect an evaluation of performance in light of generally accepted standards in the practice of Pain Medicine as reflected in relevant literature and clinical experience. The testimony should neither condemn conduct that falls within generally accepted practice standards nor support conduct that falls outside accepted medical practice. Testimony pertinent to a standard of care should take into account standards that prevailed at the time the event under review occurred. 
  3. The physician expert in Pain Medicine should be cognizant of the distinction between (a) ordinary negligence, i.e. conduct undertaken in good faith that falls below the standard of care (with consideration of a possible spectrum of standard care) and (b) gross or criminal negligence, i.e. willful disregard for the best interests of the patient or conduct so far beneath the standard of care that it shocks the conscience. Where the defendant is charged with gross negligence or criminal conduct, the physician expert should endeavor to explain whether the challenged conduct is so far outside the bounds of acceptable medical practice as to warrant imposition of punitive damages or a finding of criminality – or whether that conduct represents a good faith but negligent effort to care for the patient.
  4. The physician expert in Pain Medicine should be cognizant of the distinction between a bad outcome and negligent conduct. Sometimes, an adverse outcome, as tragic as it might be, is not the result of negligence. Thus, the physician expert should consider, and be prepared to testify to, the causal relationship between the challenged conduct and the injury at issue. In other words, the physician expert should be able to testify to whether the plaintiff’s poor outcome is the proximate result of negligent conduct by the defendant – or whether it was just an unfortunate event not fairly attributable to negligence.
  5. The physician’s fee for expert testimony should relate to the time spent in examining the facts, preparing, and testifying. In no circumstances should the fee be contingent upon outcome of the litigation.
  6. If a physician expert in pain medicine knowingly provides testimony based on a theory not widely accepted in the specialty, the physician should characterize the theory as such in his or her testimony.
  7. The Pain Medicine physician must hold the patient’s medical interest paramount, including the confidentiality of the patient’s health information, unless the Pain Medicine physician is authorized or legally compelled to disclose the information.
  8. Further guidance regarding the expert witness is found in the AAPM Ethics Charter, specifically the section on “Legal Testimony,” which should be accessed for further clarification.

Approved by the AAPM Executive Committee on April 5, 2012, and Board on June 12, 2012

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Research into the Use of Cannabinoids for Medical Purposes

Position on Research into the Use of Cannabinoids for Medical Purposes

A Position Statement from the American Academy of Pain Medicine

The American Academy of Pain Medicine (AAPM) supports regulatory rescheduling of cannabinoids from Schedule I to Schedule II to facilitate research into the medical effectiveness, substance toxicity, and overall safety of these products for the treatment of pain. The Academy is calling for this change so that a broader assessment can be made of risks and benefits related to cannabinoids as a medical option.

Major systematic reviews on the use of cannabinoids for chronic pain have yielded conflicting conclusions regarding their effectiveness and safety.1-7 The lack of high quality clinical research leaves both physicians and patients at a disadvantage when considering the potential risks and benefits of cannabinoids as medicine.

Additionally, the current disparity in some areas between state and federal laws relating to the use of marijuana for the delivery of cannabinoids results in these substances not being sufficiently regulated.8 These factors place physicians in a difficult ethical and legal position when contemplating recommending cannabinoids for their patients. Accordingly, the American Academy of Pain Medicine urges federal agencies to reschedule medical cannabis in order to encourage research leading to responsible regulation.

References

  1. Amato, L., Minozzi, S., Mitrova, Z., Parmelli, E., Saulle, R., Cruciani, F., . . . Davoli, M. (2017). Systematic review of safeness and therapeutic efficacy of cannabis in patients with multiple sclerosis, neuropathic pain, and in oncological patients treated with chemotherapy. Epidemiol Prev, Sep-Dec(41), 5-6, 279-293. doi:10.19191/EP17.5-6.AD01.069
  2. Aviram, J., & Samuelly-Leichtag, G. (2017). Efficacy of Cannabis-Based Medicines for Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Physician, Sep 20(6), E755-E796.
  3. Campbell, G., Stockings, E., & Nielsen, S. (2019). Understanding the evidence for medical cannabis and cannabis-based medicines for the treatment of chronic non-cancer pain. European Archives of Psychiatry and Clinical Neuroscience, 269(1), 135-144. doi:10.1007/s00406-018-0960-9.
  4. Mücke, M., Phillips, T., Radbruch, L., Petzke, F., & Häuser, W. (2018). Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd012182.pub2
  5. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. (2017). Washington, DC: The National Academies Press.
  6. Walitt, B., Klose, P., Fitzcharles, M., Phillips, T., & Häuser, W. (2016). Cannabinoids for fibromyalgia. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd011694.pub2
  7. Whiting, P. F., Wolff, R. F., Deshpande, S., Nisio, M. D., Duffy, S., Hernandez, A. V., . . . Kleijnen, J. (2015). Cannabinoids for Medical Use. Jama, 313(24), 2456-73. doi:10.1001/jama.2015.6358
  8. Piomelli, D., Solomon, R., Abrams, D., Balla, A., Grant, I., Marcotte, T., & Yoder, J. (2019). Regulatory Barriers to Research on Cannabis and Cannabinoids: A Proposed Path Forward. Cannabis and Cannabinoid Research, 4(1), 21-32. doi:10.1089/can.2019.0010

Approved by the AAPM Board on May 30, 2019

The Evidence Against Methadone as a “Preferred” Analgesic

The Evidence Against Methadone as a “Preferred” Analgesic

A Position Statement from the American Academy of Pain Medicine

The use of methadone as an analgesic for severe chronic pain has expanded in recent years. It is effective for some patients, but has unique pharmacologic properties that call for caution and expertise in administering it. Methadone shows up in mortality reports with greater frequency than should be expected given the small number of prescriptions written compared with other opioids. Despite this evidence of risk, most states have designated methadone as a preferred analgesic, presumably because its low cost results in savings for publicly-funded health plans. The American Academy of Pain Medicine (AAPM) takes the position that methadone should not be designated as a preferred analgesic by any insurance payer, whether public or private, unless special medical education is provided. In taking this position, AAPM concurs with the Centers for Disease Control and Prevention (CDC) that methadone should not be considered a drug of first choice for chronic pain and should only be prescribed by health-care professionals experienced in its use who follow consensus, prescribing guidelines. Though methadone is invaluable in the treatment of heroin addiction and also belongs in the armamentarium of pain medications, specific medical education is necessary for prescribing and consuming it safely, and prescriber certification to do so should be considered.

Introduction

Methadone was developed in 1937 as a synthetic opioid analgesic and introduced into the United States in 1947. It has been proven to have a role in the treatment of otherwise refractory chronic pain [Toombs & Kral 2005]; however, its clinical management can be challenging. Several of its unique properties highlight the need for special caution in the use of methadone for chronic pain.1 Reflecting its relatively long and unpredictable half-
life, methadone stays in circulation longer than many other pain medications [US FDA 2006]. Methadone’s analgesic benefits last 4 to 8 hours on average; however, methadone can remain in the body much longer: normally, between 8 and 59 hours [US FDA 2006] and even up to 130 hours due to variations in individual metabolism [Eap et al 2002]. Because of this variation, correct individual dosages are difficult to calculate a prioi. Furthermore, the waning analgesic effect as it is cleared can tempt users to take more drug than prescribed, increasing the risk for overdose due to the cumulative respiratory-depressant effect. Further risks are posed by a large number of potential drug interactions, some of which are poorly understood [Weschules et al 2008].

Methadone contributes disproportionately to opioid-related deaths. Opioids were involved in 16,651 overdose deaths in 2010, most of them unintentional [Jones et al 2013]. Methadone represents only about 2% of opioid prescriptions written but is associated with one-third of deaths, as reported by the CDC [CDC Vital Signs 2012]. By 2009, methadone- related deaths had risen six-fold over the previous decade. During that same year, nearly 4 million methadone prescriptions were written for pain.

Methadone is less expensive relative to other opioids prescribed for pain (see Table 1)[Consumer Reports 2012], a circumstance that may contribute to its frequent appearance on formularies as a drug of first choice. Payer policies that promote methadone as a preferred treatment option for chronic pain were among the factors identified by an expert panel as potential contributors to methadone mortality when prescribed for pain [Webster et al 2011]. The panel included national pain experts, regulators, health-care policy makers, and epidemiologists. In describing the risk associated with methadone prescribing, the CDC has written that methadone should not be considered a drug of first choice for chronic pain and further proposed that methadone should only be prescribed by health-care professionals experienced in its use who follow consensus prescribing guidelines [CDC MMWR 2012].

States Listing Methadone as “Preferred”

State preferred drug lists (PDLs) are approved by Pharmaceutical and Therapeutics (P & T) Committees to guide the prescribing of and reimbursement for specific prescription name- brand and generic drugs by therapeutic class. In 2003, the Centers for Medicare & Medicaid Services (CMS) first approved PDLs for use when prescribing medications for fee-for- service, publicly-funded, programs, specifically Medicaid [Hinkley & Cauchi 2012]. In general, PDLs divide drugs into two categories: drugs that are preferred and drugs that are non-preferred. (Some states divide categories of drugs into tiers in order of preference). Preferred drugs have been selected with the goal of delivering clinically appropriate medications in a cost-effective fashion. If a drug does not appear on the preferred list, an extra step such as prior authorization by the state agency or certification by the prescribing physician typically is needed before dispensing through the program can occur. In some states, the same or similar PDLs apply to other types of state-funded health coverage – such as public-employee health plans — as well as to Medicaid [Hinkley & Cauchi 2012]. In the state of Washington, the state PDL was compiled with the assistance of the Department of Labor & Industries, which handles workers’ compensation, and the Health Care Authority, which oversees state employee benefits [Washington State Social & Health Services 2007]. As the nation increases the number of insured individuals provided through Accountable Care Organizations, this transition to less expensive opioids may increase.

Table 2 shows the 33 states that list some formulation of methadone as a preferred analgesic and the 15 states that do not list it as preferred, including two (West Virginia and Nevada) that designate it as non-preferred and 13 that do not mention methadone. Two states have not published current PDLs.
State policies toward preferred or covered drugs vary. Some states that list methadone as preferred for pain offer several additional options, while others limit preferred medications more strictly. Note that Massachusetts lists methadone as covered, and New Mexico lists it as preferred; however, both states also require a prior authorization to prescribe it (Table 2).

The Risk of Methadone

A risk with methadone is incurred when payers such as Medicaid require methadone to be a preferred therapy for pain. A Pulitzer Prize-winning investigation by The Seattle Times detailed the experience of Washington state after listing methadone as a preferred drug in 2004 [Berens & Armstrong 2011]. By 2006, the number of deaths linked to methadone had doubled in the state, mainly concentrated in lower income areas. The newspaper reported that although Medicaid recipients made up only 8 percent of the state’s adult population, they accounted for 48 percent of the 2,176 methadone deaths since 2003. After the publication of this series of news articles, state officials in Washington took a number of steps to alert doctors to the special risks of methadone via educational presentations and a public-health advisory [Berens & Armstrong 2012]. Regardless, as of Nov. 1, 2013, generic methadone remained on the state’s Medicaid PDL. Washington’s Labor & Industries PDL, which lists drugs preferred for workers’ compensation benefits, did not include methadone as of July 1, 2013 [Washington State L & I 2013]. As the Affordable Care Act expands the number of people receiving Medicaid benefits, the pressure to reduce health expenditures can be expected to increase as well, along with risk for methadone toxicity if it continues to be categorized as a preferred drug.

The Position of AAPM

AAPM is opposed the use of methadone as a preferred treatment option for chronic pain and calls for manufacturers and payers to underwrite professional educational programs to educate prescribers of opioids on safe practices. A continuing medical education and certification program could serve this purpose with providers demonstrating that they

know how to use methadone and other opioids, and how to counsel patients before prescribing them.
As scientists and specialists dedicated to helping patients with pain and to furthering the practice of pain medicine, AAPM calls for payers, manufacturers and professional medical societies to commit resources nationally to resolving a knowledge deficit in prescribing practices surrounding opioids and methadone in particular. The first step in this commitment is to acknowledge that methadone’s unique pharmacologic properties make it risky to prescribe by clinicians without special training. This does not mean that other opioids are without risk and should not be interpreted as such. All opioids demand caution and training in their use for pain, and all opioids can be harmful if abused, misused, or combined with other substances that include but are not limited to other medications that depress the central nervous system, medications to treat anxiety, alcohol, and illegal street drugs.
The goal of AAPM is not to remove methadone from the armamentarium of pain medications. If methadone is chosen to treat chronic pain, all methadone prescribers should complete an education program specific to the medication.

Minimum Methadone Education Program Components

Educational programs to increase safety in the use of opioids for chronic pain, particularly extended-release and long-acting forms and methadone in particular, should include mention of primary problems identified in methadone prescribing. These include [Webster et al 2011; CDC MMWR 2012; Price et al 2014]:

  • Initiating methadone at too high a dose
  • Inflexibly applying published equianalgesic conversion tables when converting to methadone, thus failing to titrate cautiously according to the individual patient’s response
  • Underestimating the risk of respiratory depression in patients with prior opioid use
  • Titrating too rapidly
  • Failing to identify and monitor patients at risk for substance misuse or abuse
  • The risk of QT interval prolongation and possible risks with sleep apnea
  • Failure to use caution with co-prescribing of benzodiazepines, tricyclic antidepressants, and other sedatives
  • Knowledge deficits of common drug-drug interactions

Every provider who prescribes methadone for chronic pain should demonstrate proficiency on the following points [Toombs & Kral 2005; Webster & Dove 2007; Chou et al 2009; Albert et al 2011; CDC MMWR 2012]:

  • Be familiar with methadone’s unique pharmacology, e.g., long elimination half-life compared to analgesia, before prescribing it
  • Use methadone only when pain is severe enough to warrant it and when alternative treatment options are inadequate, and only after conducting a thorough risk-benefit analysis
  • Assess patients thoroughly for risk of substance abuse and mental-health comorbidities that could increase the risk of non-adherence to medical direction
  • Initiate, titrate, and rotate methadone dose conservatively, even in opioid-tolerant patients, and closely monitor patient response, particularly during dose changes 
  • Monitor patients for adherence, analgesic response, effect on daily activities, and adverse effects
  • In particular, watch for and address aberrant drug-related behaviors and psychosocial issues that could compromise therapy 
  • Monitor patients for potential cardiac toxicities and possible drug interactions, particularly with other central nervous system depressants, such as benzodiazepines and alcohol
  • Counsel patients to adhere strictly to medical direction and never to take an extra dose of methadone without checking with the prescribing clinician
  • Prepare an appropriate strategy to taper and discontinue methadone if needed
  • Receive information on naloxone kits that may be prescribed along with methadone to reduce overdose deaths

Because of variations in individual patient metabolism, including speed of distribution and vulnerability to respiratory-depressant effects, methadone calls for an individualized approach to prescribing and close monitoring. No physician should prescribe methadone unless specifically trained or advised by an expert in methadone prescribing.

Summary

Methadone’s affordability as a long-acting opioid analgesic is an advantage; however, public policies that designate methadone as a preferred analgesic for chronic pain may inadvertently contribute to toxicity and overdose. Methadone’s pharmacologic properties make it unpredictable due to a long half-life, short analgesic window relative to respiratory-depressant effect, potential for drug-drug interactions, and other issues. Payers should not designate methadone as preferred, and should support detailed and expert medical education to make the administration of all opioids, particularly extended-release and long-acting opioids and methadone in particular, safer.

1This position paper is focused on the use of methadone for pain relief only. Nothing in this document should be taken to question the value of methadone maintenance as a treatment for opioid addiction, for which there is very strong evidence of effectiveness. Citation: Strang J, Babor T, Caulkins J, Fischer B, Foxcroft D, Humphreys K. Drug policy and the public good: Evidence for effective interventions. Lancet 2012;379(9810):71-83.

Acknowledgment

Beth Dove of Dove Medical Communications, Salt Lake City, Utah, provided research and technical writing for this project.

References

Albert S, Brason FW 2nd, Sanford CK, Dasgupta N, Graham J, Lovette B. Project Lazarus: community-based overdose prevention in rural North Carolina. Pain Med 2011;12 Suppl 2:S77-85.

Berens MJ, Armstrong K. State pushes prescription painkiller methadone, saving millions but costing lives. The Seattle Times. Published Dec. 10, 2011.

Berens MJ, Armstrong K. ‘Preferred’ pain drug now called last resort. The Seattle Times. Published Jan. 27, 2012.
Centers for Disease Control and Prevention (CDC). Vital signs: Prescription painkiller overdoses: use and abuse of methadone as a painkiller. July 2012. Available at: http://www.cdc.gov/vitalsigns/MethadoneOverdoses. Accessed October 14, 2013.

Centers for Disease Control and Prevention (CDC). Vital Signs: Risk for overdose from methadone used for pain relief — United States, 1999–2010. MMWR Morb Mortal Wkly Rep 2012;61(26):493-7.

Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10(2):113-30.

Consumer Reports Best Buy DrugsTM. Using opioids to treat chronic pain: comparing effectiveness, safety, and price. Published by Consumers Union of U.S., Inc.; July 2012:17-18.

Eap CB, Buclin T, Baumann P. Interindividual variability of the clinical pharmacokinetics of methadone: implications for the treatment of opioid dependence. Clin Pharmacokinet 2002; 41(14):1153-93.

Hinkley K, Cauchi R. National Conference of State Legislatures. Medicaid Preferred Drug Lists for Mental Health and Substance Abuse; February 2012. Available at: http://www.ncsl.org/documents/health/pdl-2-2012.pdf. Accessed December 9, 2013.

Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA 2013;309(7):657-9.

Price LC, Wobeter B, Delate T, Kurz D, Shanahan R. Methadone for pain and the risk of adverse cardiac outcomes. J Pain Symptom Manage 2014 Jan 28. pii: S0885- 3924(13)00670-2.

Toombs JD, Kral LA. Methadone treatment for pain states. Am Family Phys 2005;71(7):1353–58.

U.S. Food and Drug Administration. Public health advisory: Methadone use for pain control may result in death and life-threatening changes in breathing and heart beat. U.S. Department of Health and Human Services. Silver Spring, MD, 2006.

Washington State Department of Social & Health Services Medical Assistance Administration. Medicaid’s PDL: fast facts for healthcare providers. April 2007. Available at: http://www.hca.wa.gov/medicaid/News/documents/fact_007010pdlandpreauthfax0407u pdate.pdf. Accessed December 17, 2013.

Washington State Department of Labor & Industries. Selected preferred drug list for workers. July 1, 2013. Available at: http://www.lni.wa.gov/ClaimsIns/Providers/TreatingPatients/Presc/PDL.asp. Accessed December 17, 2013.

Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners. North Branch, MN: Sunrise River Press; 2007.

Webster LR, Cochella S, Dasgupta N, et al. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med 2011;12(S2):S26-S35.

Weschules DJ, Bain KT, Richeimer S. Actual and potential drug interactions associated with methadone. Pain Med 2008:9(3):315–44.

Approved March 6, 2014

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Minimum Insurance Benefits for Patients with Chronic Pain

Minimum Insurance Benefits for Patients with Chronic Pain

A Position Statement from the American Academy of Pain Medicine

Executive Summary

The Institute of Medicine (IOM) has documented a public health crisis of chronic pain in the United States, yet the country is ill equipped to address it in the setting of the current healthcare delivery system. Patients with persistent, ongoing pain experience endemic barriers to care, many related to non-existent or insufficient insurance coverage and reimbursement for evidence- and consensus-based therapies. The result is a reductionist approach to pain management whereby the default treatments are prescription (often opioids) and procedural rather than the comprehensive, biopsychosocial approach called for by the IOM.

The American Academy of Pain Medicine (AAPM) has set a goal to advocate for a minimum set of health insurance benefits for people in pain severe enough to require ongoing therapy. The AAPM further calls for an interdisciplinary clinical approach that recognizes the interdependency of treatment methods in the treatment of chronic pain. Legislation designed to seek parity for chronic pain treatment could require that, at minimum, all payers should offer a comprehensive, interdisciplinary pain program, which would include such care modalities as cognitive-behavioral therapy, for patients who have disabling pain and have failed more conservative therapy. Reconciling the disparities between patient need and financially viable therapies can move the medical community and society forward toward safer and more effective pain care.

The Epidemic and Economic Burden of Pain

Pain affects more people than heart disease, cancer and diabetes combined, and more than 100 million suffer from chronic pain in America, according to the Institute of Medicine’s 2011 report: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research [IOM 2011]. The report illuminates the state of pain as a public health problem, stating findings and recommendations from diverse fields of medicine, epidemiology, public health, ethics, and psychology. What emerges is a picture of the extraordinary burden pain places on the nation and on individual lives, as a cause of disability and use of medical services, and in its destruction of quality of life and productivity. As a result, the IOM committee called for pain relief, research, awareness, and education to be given the status of a national priority.

Currently, health coverage standards for pain do not reflect that status. As with other medical conditions, private and public payer policies regarding pain are influenced by cost-containment imperatives. However, persistent pain is expensive in itself, costing the nation from $560 to $635 billion annually when taking into account medical costs and lower productivity due to lost time at work and lower wages [Gaskin & Richard 2012]. The total cost of pain outweighs the annual costs of the six most costly major diagnoses—cardiovascular diseases ($309 billion); neoplasms ($243 billion); injury and poisoning ($205 billion); endocrine, nutritional, and metabolic diseases ($127 billion); digestive system diseases ($112 billion); and respiratory system diseases ($112 billion)[Gaskin & Richard 2012].

In addition, the burdens imposed by prescription drug abuse and related mortality pose further public health risks. The Office of National Drug Control Policy reports that young people abuse prescription drugs second only to marijuana, and one-third of people who start using illicit drugs begin with prescription drugs [ONDCP 2011]. Moreover, prescription analgesics are associated with more than 16,000 deaths, with frequent contributions from other pharmaceuticals [Jones et al 2010].

Together, these statistics suggest it is time to look at the country’s approach to coverage and reimbursement for chronic pain therapies to align policy with the evidence base and to minimize the potential for harm associated with reductionist reimbursement strategies.

Problems With Current Coverage

The best evidence for assessment and treatment of a number of conditions (e.g., acute pain, cancer-related pain, low-back pain, musculoskeletal pain, neuropathic pain etc.) and pain comorbidities (e.g., depression) has been assembled in credible guidelines, within which the current consensus on associated therapies is also presented. One of these is the Pain Medicine Position Paper of the American Academy of Pain Medicine, which provides the following perspective on the progress toward recognizing pain as a multifactorial experience requiring a comprehensive treatment approach:

Neuroscientists were the first to recognize that the nervous system contained the substrate for pain transmission and awareness. They attempted to remove pain and suffering by devising techniques to interrupt the pain pathways. Although based on sound principles, these techniques frequently were inadequate because they failed to recognize the complex, causal interaction of biopsychosocial factors in the phenomenological pathway to chronic pain conditions and diseases and the inherent plasticity in the nervous system, which allowed the development and propagation of pain even after a noxious stimulus was removed or a nerve from a painful body area was severed [Dubois et al 2009].”

The IOM committee acknowledged the complex, challenging nature of treating chronic pain and agreed that interdisciplinary, comprehensive care is the best approach to support [Mackey 2012]. The IOM committee further called on entities that include the Department of Health and Human Services (HHS), The Veterans Administration (VA), The Department of Defense (DoD), and large healthcare providers to reduce barriers to pain care [Mackey 2012].

Unfortunately, the U.S. healthcare delivery system is rife with inconsistencies that may inadvertently push the gradient to the prescribing of pharmaceuticals in the absence of sufficient reimbursement for interdisciplinary care. In many countries around the world, the availability of interdisciplinary programs is increasing. In contrast to other industrialized nations, according to an analysis by Michael Schatman, PhD, published by the International Association for the Study of Pain, the United States now has only one interdisciplinary program for every 670,000 patients with chronic pain [Schatman 2012].

Further difficulties with current coverage include the limited time allowed to provide comprehensive services and the inconsistency of available benefits to all patients with chronic pain. Lack of uniformity, for example, was shown in the final rule for the Final Fee Schedules for Physicians and Ambulatory Surgical Centers issued by the Centers for Medicare and Medicaid Services (CMS), which featured significant cuts to physician payment when they perform epidural injections in the office setting and a 20% increase in payments for the same services performed in hospital outpatient departments [Federal Register 2013].

Insurance coverage logically affects clinical practices when it comes to therapeutic choices. For example, despite uncertain effectiveness of lumbar fusion for back pain in injured workers, California’s rates of the surgery through workers’ compensation (WC) in 2008-2009 was 47% higher than in Washington, which has a more restrictive lumbar fusion coverage policy [Martin et al 2013]. Moreover, California had higher hospital costs, more invasive surgeries, more complications and more reoperations.

An additional problem with the healthcare insurance system should be noted. The majority of states list methadone as a preferred long-acting analgesic for pain to reduce Medicaid costs [Berens & Armstrong 2011]. However, according to the Centers for Disease Control and Prevention (CDC), methadone is involved in about one-third of unintentional opioid-related overdose deaths while representing only about 2% of all opioids prescribed [MMWR 2012]. Therefore, AAPM calls on all payers, public and private, to discourage the listing of methadone as preferred or else to provide extensive and expert medical education in prescribing and consuming it.

Lack of Adequate Coverage for Treatment Options

The Uninsured and Underinsured

There is a mismatch between the widespread prevalence of chronic pain and the available insurance benefits for treatment options. According to data from the National Health Interview Survey reported by the CDC, 47.3 million persons of all ages were uninsured during the first three months of 2012 [Cohen & Martinez 2012]. By the end of December 2013, during the initial enrollment period under the Affordable Care Act of 2010, nearly 2.2 million people enrolled to receive coverage [HHS 2014] but significant numbers remain uninsured. Low incomes associated with uninsured status further limit access to medical services and may relegate the population to the lowest cost, generic prescriptions, which may or may not be optimal.

Barriers to Coverage for the Insured

An additional segment of the population is underinsured, having access to coverage that limits benefits or requires out-of-pocket of expenses that may put many services out of reach for lower income people. Despite protections to coverage provided under the Affordable Care Act, an analysis by Avalere Health reported in Kaiser Health News found that many people with chronic conditions may still be underinsured, spending greater than 10% of their incomes on medical care, excluding premiums [Andrews 2014]. In addition, access to specialist care and services such as physical therapy are expected to be subject to limitations [Andrews 2014].

At times the indication of chronic pain is itself a limitation to adequate coverage. For example, Public Employees Health Plan in Utah as of 2007 limited benefits to 50% of the cost of services to people with a diagnosis of chronic pain after five visits [written communication from Marilyn Dillon, CPC, president at Certified Medical

Billing Systems, Salt Lake City, Utah, May 23, 2013]. Considered against the background of the significant impairment that often limits the earning abilities of many patients with chronic pain, it is clear that many therapies must remain out of reach. Furthermore, standard commercial insurance policies routinely limit complementary and alternative therapies and comprehensive interdisciplinary care.

Minimum Benefits for Pain Patients

The idea of developing a program of mandatory benefits, as espoused in this paper, would extend to pain “severe enough” to potentially benefit from such treatment, that has failed or is expected to fail more conservative therapy, and that is not expected to resolve within the foreseeable future. At minimum, a proposed program of treatment categories should include the following framework:

  1. Medical management
  2. Evidence- or consensus-based interventional/procedural therapies
  3. Ongoing behavioral/psychological/psychiatric therapies
  4. Interdisciplinary care
  5. Evidence-based complementary and integrative medicine (CIM – e.g., yoga, massage therapy, acupuncture, manipulation)

The parity in coverage for people with pain should be similar to that accorded people with mental-health disorders [MHPAEA 2008]. Limited visits and reimbursement is not appropriate for patients who have ongoing, sometimes progressive, incurable pain conditions.

Evidence for Interdisciplinary Care

Traditionally, pain care has adhered to a medical model, primarily delivered by physicians. In 1953, John Bonica, MD, launched a new era in thinking about multispecialty pain care with the publication of his textbook, “The Management of Pain [Bonica 1953].” Bonica wrote of pain disorders as complex and multi- dimensional and proposed that a multispecialty team should treat pain. In a white paper published in 2010, the American Pain Society further distinguished between “multidisciplinary” care, in which multiple specialties may operate independently of one another, and “interdisciplinary” care, which is preferred and is marked by specialists working collaboratively to treat all aspects of a patient’s pain (e.g., underlying pathology, behavioral, and psychosocial)[Turk et al 2010]. However, the terms multidisciplinary and interdisciplinary care are used interchangeably within this document when discussing study results that used terminology understood to apply to delivery of care using multiple disciplines.

Building on work from the International Association for the Study of Pain, Turk and fellow APS colleagues listed members that may comprise an interdisciplinary team, contingent upon the patient population and disorders being treated [Turk et al 2010]:

  • Patient
  • Family
  • Physicians (e.g., physiatrist, anesthesiologist, addictionologist)
  • Nurses
  • Psychologists
  • Physical therapists
  • Occupational therapists
  • Recreational therapists
  • Vocational counselors
  • Pharmacists
  • Nutritionists/dieticians
  • Social workers
  • Support staff
  • Volunteers
  • Others

The key is collaboration among the various providers to deliver effective care to the patient. To work effectively together, the interdisciplinary care team must communicate openly; share common and measurable goals; deliver customized, evidenced-based, multimodal therapies; document progress and share feedback; refer patients to other healthcare providers as appropriate; encourage active patient participation; and share systematic quality improvement efforts; among other strategies [Turk et al 2010]. After discharge from the interdisciplinary care program, maintenance is provided by a primary care physician with ongoing therapeutic care and feedback from the interdisciplinary team members, as needed.

Interdisciplinary care has a significant evidence base in the treatment of chronic nonmalignant pain, which is not reflected in insurance coverage policies as noted by the APS authors who wrote:

… despite the large and growing body of research supporting both the clinical effectiveness and cost-effectiveness of interdisciplinary care, there continues to be reluctance among third-party payers to cover the costs of all components of such care. This is somewhat of a paradox — in the days when there are calls for evidence- based health care and when pay-for-performance has become something of a mantra, there is continuing refusal to pay for the care with the best evidence. [Turk et al 2010].

The following brief summary of relevant literature pertaining to interdisciplinary pain care programs begins with a seminal 1992 meta-analysis. Comprising 65 studies and encompassing 3,089 patients, the study found superior effects of multidisciplinary treatments for chronic back pain compared with no treatment, waiting list and single-discipline treatments such as medical treatment or physical therapy [Flor et al 1992]. Most programs included psychological and medical treatments as well as physical or occupational therapy and lasted an average of seven weeks. Measures of pain and mood improved and held steady over time as did behavioral variables, including return to work or healthcare utilization.

A Cochrane Review to study chronic pelvic pain interventions in women found a single high-quality randomized, controlled trial (RCT) including 106 patients that compared standard care to multidisciplinary treatment, encompassing physiotherapy, psychology and attention to dietary and environmental factors [Stones & Mountfield 2002]. Follow-up was for one year, and a positive multidisciplinary care outcome was found via a self-rating scale and daily activity (Odds Ratio: 4.15, 95% confidence interval 1.91 to 8.99) though not on pain scores. The authors concluded evidence supports multidisciplinary care in this patient population based on the single RCT.

A qualitative review by Guzmán and colleagues of 10 randomized, controlled trials compared care that was coordinated among multiple disciplines to non- multidisciplinary rehabilitation or usual care for patients with disabling low-back pain [Guzmán et al 2002]. The investigators graded strength of evidence rather than pooling effects for meta-analysis, citing heterogeneity of study methodologies. They found strong evidence of improved function and moderate evidence for improved pain with >100 hours of multidisciplinary, biopsychosocial rehabilitation with a functional restoration approach. At less intensive use (<30 hours), evidence was limited.

However, relatively short treatment durations of intensive interdisciplinary care have been shown to be of benefit for patients who suffer from chronic back pain. Significant pain intensity (67%) and functional (33%) improvements were achieved within three weeks in an interdisciplinary outpatient setting for patients with back pain and sciatica [Artner et al 2012], although the methodologies and concepts of the study have been called into question [Kaiser et al 2013]. The therapeutic regimen in this pilot program consisted of interventional injection techniques, medication, exercise therapy, back education, ergotherapy, traction, massage therapy, medical training, transcutaneous electrical nerve stimulation, aquatraining and relaxation.
The literature supporting interdisciplinary care in back and pelvic pain is counterbalanced by two qualitative reviews that returned less conclusive results, one for fibromyalgia and widespread musculoskeletal pain in 1,050 patients [Karjalainen 2000] and another for shoulder and neck pain that included 177 patients [Karjalainen 2001]. The benefits of multidisciplinary care were uncertain based on a limited level of evidence and inconsistent findings among low-quality, under-powered RCTs [Ospina & Harstall 2003].

Improvements in study design and reporting methods are needed in research going forward. Regardless, interdisciplinary pain care programs are lacking adverse effects common to pharmacotherapy and interventional procedures [Schatman 2011], have evidence for long-term treatment gains of up to 13 years [Patrick et al 2004], and have demonstrated clear cost effectiveness compared with conventional medical treatments for chronic pain [Gatchel & Okifuji 2006].

The 2010 Practice Guidelines from the American Society of Anesthesiologists and the American Society of Regional Anesthesia and Pain Medicine is a credible, evidence-based source that states the multi-specialty therapeutic approach is a legitimate treatment strategy for patients with chronic pain [ASA 2010]. The guideline task force found evidence of multiple RCT’s that multidisciplinary treatment programs are effective compared with conventional treatment programs in reducing pain intensity reported by patients for periods ranging from four months to one year. The task force did not find sufficient RCTs to conduct a meta-analysis, nor was evidence adequate to compare multimodal therapies with single modality therapies.

The “Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non- Cancer Pain” cites evidence that patients with severe pain and pain-related disability who are treated with opioids have better outcomes when managed in multidisciplinary pain clinics [Canadian guideline 2010]. The guideline goes on to note that treatment modalities and diagnostic approaches vary among such programs, which are not widely available in Canada.

As suggested by these references, the philosophical evolution in care advanced herein is representative of a broad, evidence-guided, clinical consensus. Of course, gaps exist in the evidentiary link between bench science and clinical effectiveness for a range of therapies throughout all of medical practice; these gaps are not limited to Pain Medicine. But the decision to withhold or refuse payment for any therapeutic modality until all such gaps are closed is neither practical nor ethical.

Of late, there are some encouraging signs that payer policies are beginning to align with science. A policy from Aetna insurance, updated in May 2013, quotes relevant supporting evidence and concludes that the interdisciplinary/multidisciplinary treatment approach should be covered for members who meet the all of the following criteria [Aetna 2013]:

If a surgical procedure or acute medical treatment is indicated, it has been performed prior to entry into the pain program

  • Member has experienced chronic non-malignant pain (not cancer pain) for six months or more
  • Member has failed conventional methods of treatment
  • Member has undergone a mental health evaluation, and any primary psychiatric conditions have been treated, where indicated
  • Member’s work or lifestyle has been significantly impaired due to chronic pain
  • Referral for entry has been made by the primary care physician/attending physician
  • The cause of the member’s pain is unknown or attributable to a physical cause, i.e., not purely psychogenic in origin

Evidence for Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) represents an important and viable treatment modality within the broader spectrum of pain management. It is a psychological intervention that incorporates cognitive restructuring and the teaching of behavioral techniques to alter behavior. There is an emphasis on learning, personal control, expectations and problem solving [Veehof et al 2011]. Several recent meta- analyses of CBT (and other psychological therapies) for chronic pain have found significant benefits for pain intensity and other outcomes that include depression and pain-related interference [Veehof et al 2011; Hoffman et al 2007; Williams et al 2012].

In a meta-analysis of 22 randomized controlled trials, reviewers found benefits for psychological intervention – particularly CBT and self-regulatory treatments — in chronic low-back pain in the areas of pain intensity, pain-related interference, health-related quality of life, and depression compared with control treatment groups [Hoffman et al 2007]. Short-term pain interference and long-term return to work measures were better with a multidisciplinary treatment approach that included a psychological component when compared with active controls.

A Cochrane Review that included 35 studies with 4,788 participants found improved pain, disability, mood, and catastrophizing immediately after treatment in patients with chronic pain (excluding headache) when compared with usual treatment and waiting list [Williams et al 2012]. Improvements in mood were maintained at six months but not for pain and disability.

In a systematic review and meta-analysis of acceptance-based therapies (e.g., mindfulness techniques), investigators found an effect size on pain of 0.37 in 14 controlled studies and an effect size on depression of 0.32, outcomes that were equivalent to those of CBT [Veehof et al 2011]. The authors concluded CBT is still standard treatment, but that other therapies could supplement as matched to patient characteristics. They further suggested, for future research purposes, that measures other than pain intensity (e.g., pain interference) may better describe the benefits reported by patients.

A Cochrane Review found CBT to be moderately superior to a wait-list control for short-term pain intensity in chronic low-back pain (standardized mean difference, 0.59 [CI, 0.10 to 1.09]), but not for functional status (standardized mean difference, 0.31 [CI, −0.20 to 0.82])[Ostelo et al 2005].

In summarizing the evidence of meta-analyses conducted over the last two decades, Morley and colleagues recently concluded that, overall, CBT has a beneficial average effect for disability, depression and the pain experience without evidence of harm [Morley et al 2013]. To reduce the dilution effect of poorly designed and executed trials, the authors further called to improve investigation methods to better study CBT and its effect.

Though numerous studies show CBT to be effective for chronic pain, most commonly when delivered as part of multidisciplinary care but also as a single modality, some patients appear to benefit more than others [McCracken & Turk 2002]. Those more oriented toward self management, with more positive emotional perceptions toward pain and perceived disability, do better than patients who see their pain as uncontrollable and who suffer high distress accordingly [McCracken & Turk 2002]. This type of study and analysis to identify which patients benefit from CBT should continue.

In general, CBT for chronic pain is time limited, of 6 to 10 weeks duration. The magnitude of the effects is generally small-to-moderate, and benefits for CBT extend to adults, children and older adults. However, symptom alleviation, particularly for adults, is not always long lasting. Of note, most analyses examine CBT alone rather than CBT as part of a multidisciplinary approach, which would be the ideal clinical scenario. The lack of adverse effects for CBT combined with clinical benefits that are similar in magnitude to biomedical treatments (which do produce adverse effects), bolsters the argument to extend coverage for CBT.

Recommendations

In all tiers of the healthcare system, from the uninsured to those on public and private plans, coverage is needed for comprehensive, interdisciplinary modalities of treatment like CBT, physical therapy, stress management, rehabilitation, complimentary and integrative therapies (CIM) and alternative therapies and medications that are known to be effective and safer than usual care.

At minimum, all payers should provide three months coverage for an interdisciplinary integrative pain evaluation and treatment program for people with pain that is severe enough to warrant ongoing therapy, that has failed or is not expected to respond to first-line therapies, and that is not expected to resolve in the foreseeable future.

The Mental Health Parity and Addiction Equity Act requires insurance groups that offer coverage for mental health or substance use disorders to provide the same level of benefits as for medical treatment [MHPAEA 2008]. In a similar but distinct parity arrangement, we propose mandated coverage for CBT but recommend that such therapy be covered as part of medical management of pain, not behavioral management. This recommendation aligns with the necessary base of expertise and services within pain management needed to appropriately treat patients with chronic pain.

In addition, coverage for monitoring measures to reduce the abuse and diversion of prescribed medication should extend to urine drug testing and checks of the state prescription monitoring database, where available. These measures are supported by fair evidence of benefit for patients on opioids for chronic pain management and, although subject to limitations, are considered essential by experts in the field [Manchikanti et al 2012; Chou et al 2009].

A further strategy is to align incentives with patient outcomes rather than the current fee-for-service reimbursement that rewards volume over quality. When outcomes are rewarded, clinicians are more likely to use therapies seen to be effective.

Additionally, it is recommended that payers work with providers to set up bundles, or some form of “global fee” that covers pain diagnoses. A predetermined payment to a healthcare provider or group based on historical reimbursement for all services related to a specific diagnosis is one possible method to align incentives. Such an approach could allow for bundled services that include behavioral therapy, education, training, medical management, and physical therapy or rehabilitation. Care must be taken to adjust for higher risk and to tie financial incentives to patient outcomes. Given careful structuring and adequate oversight, alternative payment systems could allow for cost control while extending interdisciplinary care to many more patients with pain.

Summary

To address the country’s pain crisis with competence and compassion, it is necessary to improve the healthcare delivery system so that comprehensive treatment is available to all patients with chronic pain. It is the responsibility of AAPM to help effect change in these areas through elucidating the science and providing the leadership to make a difference in these key areas. Comprehensive treatment of chronic pain draws from multiple disciplines to address physical and psychosocial components of pain. The interdisciplinary approach may encompass some combination of the following therapeutic areas:

  • Medical management
  • Physical therapy
  • Occupational therapy
  • Biofeedback
  • Vocational and recreational therapy
  • Psychological counseling (e.g., CBT)
  • Complementary and Integrative Medicine

The pain community’s efforts to date have been largely conceptual identifying the need for change but no specific steps identified to move forward. To move from the conceptual to the practical and tangible will require alliance of organizations interested in making the world better for people in pain.

Acknowledgment

Beth Dove of Dove Medical Communications, Salt Lake City, Utah, provided research and technical writing for this project.

References

Aetna Clinical Policy Bulletin: Chronic Pain Programs. Last review: May 10, 2013. Available at: http://www.aetna.com/cpb/medical/data/200_299/0237.html. Accessed January 21, 2014.

American Society of Anesthesiologists Task Force on Chronic Pain Management; American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010;112(4):810- 33.

Andrews M. Despite health law’s protections, many consumers may be ‘underinsured.’ Kaiser Health News; 2014. Available at: http://www.kaiserhealthnews.org/stories/2013/december/31/michelle-andews- health-law-protections-consumers.aspx. Accessed January 23, 2014.

Artner J, Kurz S, Cakir B, Reichel H, Lattig F. Intensive interdisciplinary outpatient pain management program for chronic back pain: a pilot study. J Pain Res 2012;5:209-16.

Berens MJ, Armstrong K. State pushes prescription painkiller methadone, saving millions but costing lives. The Seattle Times. Published Dec. 10, 2011.

Bonica JJ. The Management of Pain, with Special Emphasis on the Use of Block in Diagnosis, Prognosis and Therapy. Philadelphia, PA: Lea & Febiger; 1953.

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Canada: National Opioid Use Guideline Group (NOUGG); 2010. Available from: http://nationalpaincentre.mcmaster.ca/opioid/ Accessed January 21, 2014.

Centers for Disease Control and Prevention (CDC). Vital signs: risk for overdose from methadone used for pain relief – United States, 1999-2010. MMWR Morb Mortal Wkly Rep 2012;61(26):493-7.

Chou R, Fanciullo GJ, Fine PG, et al, American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10(2):113-30.

Cohen RA, Martinez ME. Health insurance coverage: Early release of estimates from the National Health Interview Survey, January−March 2012. National Center for Health Statistics. September 2012. Available at: http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201209.pdf. Accessed December 30, 2013.

Dubois MY, Gallagher RM, Lippe PM. Pain medicine position paper. Pain Med 2009;10(6):972-1000.

Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992;49(2):221-30.

Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012;13(8):715-24.

Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain 2006;7(11):779-93.

Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary bio-psycho-social rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2002;(1):CD000963. Review.

Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol 2007;26(1):1-9.

Institute of Medicine of the National Academies. Relieving pain in America: a blueprint for transforming prevention, care, education, and research [report brief]. Sponsored by the National Institutes of Health. Washington, DC; June 2011, Revised March 2012.

Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA 2013;309(7):657-9.

Kaiser U, Arnold B, Pfingsten M, Nagel B, Lutz J, Sabatowski R. Multidisciplinary pain management programs. J Pain Res 2013;6:355-8.

Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults. Cochrane Database Syst Rev 2000;(2):CD001984.

Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group.
Spine (Phila Pa 1976) 2001;26(2):174-81.

Mackey S. Pain in the United States: a review of our country’s experience with pain. San Francisco Medicine: Journal of the San Francisco Medical Society. 2012; 83(3):26-7.

Manchikanti L, Abdi S, Atluri S, et al, American Society of Interventional Pain Physicians. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I–evidence assessment. Pain Physician 2012;15(3 Suppl):S1-65.
Martin BI, Franklin GM, Deyo RA, Wickizer TM, Lurie JD, Mirza SK. How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers’ compensation systems. Spine J 2013. pii: S1529-9430(13)01465-4.

McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine (Phila Pa 1976) 2002;27(22):2564-73.

Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value- Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic Health Records (EHR) Incentive Program; Provider Reimbursement Determinations and Appeals. Fed Reg. 78:237 (Dec. 10, 2013) p. 74826.

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008; Technical Amendment to External Review for Multi- State Plan Program. Fed Reg. 78:219 (Nov. 13, 2013)] pp. 68239-68296.

Morley S, Williams A, Eccleston C. Examining the evidence about psychological treatments for chronic pain: time for a paradigm shift? Pain 2013;154(10):1929-31.

Office of National Drug Control Policy. Epidemic: Responding to America’s Prescription Drug Abuse Crisis. White House Web site. http://www.whitehouse.gov/sites/default/files/ondcp/issues- content/prescription-drugs/rx_abuse_plan_0.pdf. Released 2011. Accessed August 12, 2013.

Ospina M, Harstall C. Multidisciplinary pain programs for chronic pain: evidence from systematic reviews. HTA 30: Series A Health Technology Assessment. Alberta Heritage Foundation for Medical Research. Edmonton, Alberta, Canada;
2003.

Ostelo RW, van Tulder MW, Vlaeyen JW, Linton SJ, Morley SJ, Assendelft WJ. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev 2005;(1):CD002014.

Patrick LE, Altmaier EM, Found EM. Long-term outcomes in multidisciplinary treatment of chronic low back pain: results of a 13-year follow-up. Spine (Phila Pa 1976) 2004;29(8):850-5.

Schatman ME. Interdisciplinary chronic pain management: international perspectives. Pain: Clinical Updates. December 2012;XX(7). Website of the International Association for the Study of Pain. Available at www.iasp-pain.org. Accessed December 30, 2013.

Schatman ME. The role of the health insurance industry in perpetuating suboptimal pain management. Pain Med 2011;12(3):415-26.
Stones RW, Mountfield J. Interventions for treating chronic pelvic pain in women (Cochrane Review). In: The Cochrane Library Oxford: Update Software 2002;(4).

Turk DC, Stanos SP, Palermo TM, et al. Interdisciplinary Pain Management [white paper]. Glenview, IL: American Pain Society; 2010.

U.S. Department of Health & Human Services, ASPE Office of Health Policy. Health insurance marketplace: January enrollment report for the period: October 1, 2013 – December 28, 2013. ASPE Issue BRIEF; January 2014.

Veehof MM, Oskam MJ, Schreurs KM, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta- analysis. Pain 2011;152(3):533-42.

Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2012;11:CD007407.

Approved March 7, 2014

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For the Primary Care Provider: When to Refer to a Pain Specialist

For the Primary Care Provider: When to Refer to a Pain Specialist

A recommendations statement from the American Academy of Pain Medicine

The American Academy of Pain Medicine’s (AAPM) Shared Interest Group in Primary Care provided a forum for pain specialists and primary care clinicians to gather and address clinical areas of concern for their patients. With the understanding that most chronic pain care takes place in conjunction with a patient’s primary care provider, the Primary Care SIG members have collaborated on the creation of a document meant to assist primary care providers in providing their patients the best of chronic pain care. A key aspect in providing that care is knowing when to refer to a pain specialist.

These recommendations are not intended to dissuade primary care practitioners who are not pain specialists from managing chronic non-cancer pain patients in the primary care setting. Rather, the intent is to further enable primary care providers to improve the effectiveness and safety of the care they offer to their patients living with chronic pain. Some key points are provided below.

  • Chronic pain like all chronic medical illness requires patient self-management. Cure is rare and complete pain relief is rarer. Patients do best when they adopt a new lifestyle not solely dictated by the pain. The provider does best by offering support and encouragement; not necessarily by more testing, more medication, more referrals, or more procedures.
  • When to refer will depend on the expertise of the primary care provider and the availability of the pain specialist.
  • All pain practitioners/clinics are not the same. The referral may vary from a referral to a pain specialist who utilizes a single modality to interdisciplinary rehabilitation models. It is important to know who is available for consultation, what the specialist offers, and what expectations both the patient and the provider bring to the referral.
  • It is important to foster communication and develop relationships between a primary care and a specialist. This encourages collaboration on what may be a challenging patient population. Collaboration includes sharing medical records, jointly determining treatment plans, care coordination, etc.
  • Chronic pain can be defined in a variety of ways. Most experts agree that pain longer than the expected time of healing is a useful definition. Referral for evaluation and treatment early is important to break the cycle of chronicity and to aid in de-conditioning.
  • Know your state regulations and guidelines which may require referral at certain milestones such as milligram limits. For example, the CDC guidelines recommend extra precaution when prescribing 50mg or more morphine equivalents a day and avoiding 90mg or more. Referral of
    patients hitting these thresholds may be advisable for expert guidance as these thresholds indicate greater risk AND may indicate a failure of opioids to achieve functional goals. The specialist can assist in expanding the self-care training and other portions of the treatment plan.
  • Chronic pain may not have a known, easily definable cause despite an extensive primary care work up (e.g., low back pain, fibromyalgia, chronic daily headaches, etc.). Referral to a pain specialist to confirm or establish the diagnosis and offer suggestions on management is advisable.
  • If a procedure is indicated (e.g., low back pain with radiculopathy) or surgery is indicated (progressive neurologic deficit, cauda equina syndrome, etc.), a referral should be considered.
  • Chronic pain often co-exists with anxiety, depression, bipolar disorder, PTSD, and other psychiatric conditions. A referral to behavioral health services to optimize the management of these conditions may facilitate management of chronic pain.
  • If the cause of the pain is known (or unknown), serious disease excluded, no curative treatment is readily available, current treatment is not helping, or the pain interferes with daily function, referral should to a pain specialist should be considered.
  • If the primary care provider begins to feel uncomfortable continuing the current treatment with the chronic pain patient, referral is indicated. A primary care provider should never be compelled to provide treatments beyond his or her level of training or expertise.
  • A positive urine drug screen for abusable medications and/or clear evidence of misuse or abuse requires a frank, honest discussion with the patient which often means tapering treatment medications. An addiction specialist, rather than a pain specialist, is often a more appropriate consultation.

Reference:
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;65(1):1–49.

###

The members of the American Academy of Pain Medicine Primary Care Shared Interest Group are pleased to share these observations and recommendations in the interest of ensuring better patient care.

December 1, 2016

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AAPM Statement on Scope of Practice in Pain Medicine

Scope of Practice in Pain Medicine

A position statement from the American Academy of Pain Medicine

Whereas, The American Academy of Pain Medicine is dedicated to the safe and appropriate care of the patient suffering from pain through the practice of Pain Medicine.

Whereas, The American Academy of Pain Medicine (AAPM) believes that a Pain Medicine practitioner is a physician who, by academic medical degree and clinical post-graduate training, board certification, continuing medical education in Pain Medicine and a license to practice medicine, is uniquely qualified to provide a comprehensive array of professional services related to the medical specialty of Pain Medicine. The practice of this specialty involves the identification, diagnosis and treatment of persons with chronic pain symptoms, and often complex, chronic pain conditions to which many diseases may contribute.

Whereas, The medical specialty of Pain Medicine is currently recognized by the American Board of Pain Medicine and by the American Board of Medical Specialties as a subspecialty of anesthesiology, physical medicine and rehabilitation, neurology, and psychiatry.

Whereas, The American Academy of Pain Medicine believes that the physician is called upon to make continuing adjustments based on medical judgments drawn from patient response to treatment. With regard to interventional therapies (e.g., injections, surgical procedures), it is not the procedures itself, but the purpose and manner in which such procedure is utilized, that demands the ongoing application of direct and immediate medical judgment, which constitutes the practice of medicine. A non-physician may have education, training and, indeed, expertise in such area but expertise cannot, in and of itself, supply authority under law to practice medicine.

Whereas, The American Academy of Pain Medicine believes that hospital credentialing committees must have policies in place that restrict credentialing of non-physician clinicians for positions that are not within their respective scope of practice.

Whereas, The American Academy of Pain Medicine encourages and supports state medical boards and state medical societies in adopting advisory opinions and advancing legislation, respectively, that the practice of Pain Medicine constitutes the practice of medicine.

Whereas, The American Academy of Pain medicine believes that the practice of the Specialty of Pain Medicine includes the diagnosis and treatment of a variety of acute and chronic medical conditions, many of which are lifelong in duration, and may be life-threatening in severity. As such, the practice of the Specialty requires postgraduate medical training sufficient for expertise in the diagnosis and multimodal management of the full spectrum of pain conditions, which regularly entails the ongoing utilization of medical decision making requiring the expertise of an adequately trained and skilled physician. As the performance of interventional pain procedures is a necessary and integral part of the practice of Pain Medicine, it is the position of the AAPM that interventional pain procedures, and surgeries, be performed by a physician with sufficient training and expertise for the performance of any given procedure, as are the standards in other interventional and surgical subspecialties in medicine.

RESOLVED, The practice of Pain Medicine is the practice of medicine by a physician. Anyone who practices Pain Medicine and is not a physician is out of their scope of practice and should be held accountable for adverse outcomes. Patients expect and deserve the best in medical care, and when their care entails the practice of Pain Medicine, that care should only be offered by licensed and properly trained physicians to ensure the health and safety of all patients.

Approved by the AAPM Executive Committee on September 6, 2017

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American Academy of Pain Medicine