Sarasota, FL (WorkersCompensation.com) – Are best practices for treating chronic pain the best we can do? Or are there areas for improvement? A federal task force looking into the issue says there is much more that can be done, particularly as it relates to the Centers for Disease Control and Prevention’s opioid prescribing guidelines.
Workers’ compensation pain specialists agree with parts, if not most of the task force’s draft report – especially as it pertains to the CDC guidelines. But they question what, if any, impact the report will have.
Called the Pain Management Best Practices Inter-Agency Task Force, the 29 member have backgrounds in pain management, patient advocacy, substance use disorders, mental health and minority health. It was created by the Department of Health and Human Services as part of the Comprehensive Addition and Recovery Act of 2016. Its mission is to “determine whether gaps or inconsistencies between best practices for acute and chronic pain management exist,” and, if so, “propose updates and recommendations.”
Among the initial key concepts in the task force’s draft report are:
- Balanced pain management should be based on a biopsychosocial model of care
- Individualized, patient-centered care is vital to addressing the public health pain crisis
- Ensure better and safer opioid stewardship through risk assessment based on patients’ medical, social, and family history to ensure safe and appropriate prescribing
- Access to care is vital through improved health care coverage for various treatment modalities and an enlarged workforce of pain specialists and behavioral health clinicians to help guide and support appropriately trained primary care clinicians
- Education through societal awareness, provider education and training, and patient education are needed to understand choices and promote therapeutic alliances between patients and providers
In terms of the CDC opioid guidelines, the report noted that they provide “useful general guidance for prescribing opioids,” but that “important limitations have been highlighted” since they were released nearly 3 years ago.
Workers compensation pain experts agree with the report’s comments that the CDC guidelines:
- Are being used inappropriately as model legislation for state laws, instead of as guidance for providers
- Don’t address legacy patients on opioids
- Have prescribing limits that fail to account for individual differences, in some cases forcing patients to reduce their dosages or taper off the drugs
- Are unenforceable
Among the biggest unintended consequences of the guidelines is what some say is its over simplistic approach. Prescribing limits and required pre-authorizations, for example, can impede the process of helping injured workers get off opioids.
“Say a patient wants to get off opioids; they’ve been buying heroin, oxycontin, or whatever. We say ‘we’ll manage you with medication-assisted treatment.’ They take the prescription to the pharmacy, but it must be preauthorized, which takes 72 hours. What do you think the patient does in those 72 hours?” said Sanford M. Silverman, MD, principal of Silver Lining Medical Consultants, member of the Board of Trustees of the Broward County Medical Association, and past president of the Florida Society of Interventional Pain Physicians. “The guidelines work against doctors who are trying to help legacy patients because they can’t get the help they need to taper the person off the opioids.”
Injured workers and others who have become dependent on opioids cannot be cut off cold turkey from the drugs without suffering serious consequences. Weaning them requires careful monitoring.
“Tapering [off opioids] is dangerous,” said Michael Coupland, network medical director of Integrated Medical Case Solutions. “That’s why you need somebody with a lot of skill. There can be side effects and possible death” if the tapering is done too fast or inappropriately.
Coupland’s company has documented significant success using cognitive behavioral therapy-based programs to help injured workers with chronic pain and/or those with opioid dependence. He said the guidelines should not be viewed as the total solution to the issue.
“It’s great that they promote biopsychosocial treatments,” he said, “but it’s not good that they take a one-size-fits-all approach.”
That approach, for example, does not take into account injured workers and others who are better able to function with higher doses of opioids. “Many patients who are stable on higher than 120 morphine equivalent dose per day – maybe 180 or 200 – are being forced to get to a lower dose. It’s very difficult to do this,” Silverman said. “Or worse, they see their primary care doctor who says ‘I can’t see you,’ so the patient must see another person.”
One problem Silverman and Coupland cited is that the CDC guidelines, and the report that ultimately goes to Congress, are unenforceable.
“A balanced approach to pain? Insurance companies are denying that left and right.” Silverman said. “I think everything in this report is great, but we can’t get this stuff done. There’s a problem with access … doctors are buried alive with prior authorizations for MRIs, medications; trying to get a behavioral consult or CBT, you wait weeks and it may not be covered.”
The task force is accepting comments through April 1, and will then send its final report on to Congress.