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CDC Seeks Individual Perspectives on the Management of Acute and Chronic Pain – Comments due Aug. 21

 The Centers for Disease Control and Prevention (CDC) recently announced an opportunity for stakeholders to share their individual perspectives on and experiences with pain and pain management, including but not limited to the benefits and harms of opioid use. Patients with acute or chronic pain, patients’ family members and/or caregivers, and healthcare providers who care for patients with pain or conditions that can complicate pain management (e.g., opioid use disorder or overdose) will be considered for participation.

CDC will hold approximately 100 individuals, 45- to 60-minute conversations with selected stakeholders over the phone or through an internet-enabled virtual platform. Input gathered through these conversations will help inform CDC’s understanding of stakeholders’ values and preferences relate to pain and pain management and will complement its ongoing work to update the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

The conversations are intended to supplement the written comments on the same subject, gathered through a June docket. AAPM responded to this initial call, submitting feedback on the following topic areas:

  • Opioids for chronic non-cancer pain; appropriate and safe opioid analgesic prescribing for chronic pain
  • Opioids for acute, post-surgical pain; risks of prolonged opioid prescribing
  • Opioid taper indications/strategies
  • Interdisciplinary pain management best practices
  • Barriers for multidisciplinary chronic pain management
  • Pain management education
  • Pain care measurement and monitoring strategies
  • Substance use disorder (SUD) screening, prevention and treatment; co-managing pain and SUD
  • Mental health care access
  • Pain management research and funding

Persons interested in participating in the current call for comments should contact CDC no later than 5:00 p.m. EDT August 21, 2020. 

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.

About AAPM
The American Academy of Pain Medicine is the premier medical association for pain clinicians and their treatment teams with some 2,000 members. Now in its 36th year of service, the Academy’s mission is to advance and promote the full spectrum of multidisciplinary pain care, education, advocacy, and research to improve function and quality of life for people in pain. Information is available on the Academy’s website at painmed.org.

Approved by the AAPM Executive Committee on June 15, 2020

Message from the AAPM President about COVID-19

​AAPM has been monitoring CDC guidance related to COVID-19. Today AAPM President Ajay D. Wasan, MD MSc issued the following message to members.

Dear Colleagues:

By now I am sure that you have received many lengthy COVID emails and so I will get to the point. AAPM has been monitoring CDC guidance related to COVID-19, and we offer the following thoughts to our members:

The CDC suggests delaying and not having patients come into the office for elective medical care. Certainly, it is a difficult issue to determine to what extent pain care is ‘elective’ vs. medically necessary, and the consideration for limiting outpatient pain care also depends on the extent of COVID-19 and the risk of acquiring it in your area.

At the very least it seems prudent to reschedule elective procedures/injections, initial evaluations, and follow-up visits in those patients at a high risk of complications from COVID-19. These subgroups include those 65 years old or older, those with important medical comorbidities (such as cardiac disease, pulmonary disease, or diabetes), the immunocompromised, and patients coming from nursing homes or long-term care facilities.

The CDC and the Trump administration have encouraged telemedicine visits in place of in-person follow up visits for elective medical care. The DEA has confirmed that it is reasonable in this crisis to renew controlled substance prescriptions after a telemedicine evaluation or telephone discussion with the patient when appropriate and if consistent with state law (such as by electronic prescribing to avoid a high risk patient coming in for a routine opioid follow up visit).

CMS has also relaxed the requirements for using telemedicine codes for billing and they have pledged to pay for these codes equivalent to in person visits. There are weblinks below that explain further how to use these codes effectively in your practice.

We are all struggling to adjust—both professionally and personally. In the coming weeks, our American Academy of Pain Medicine (AAPM) will work to keep us abreast of developments that are specific to our practice areas. Initially, we are providing updated billing and coding guidance that are consistent with the latest messaging coming from CMS regarding the expanded use of telemedicine codes. These insights were prepared under the guidance of the AAPM’s Coding and Reimbursement Committee, which represents our specialty at the CPT and RUC, and regularly provides information to AAPM members in the bi-monthly AAPM e-Newsletter.

Our AAPM will continue to monitor developments that are particular to pain medicine. Thank you for your continuing efforts on behalf of our patients.

Ajay D. Wasan, MD MSc
President AAPM

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