EXECUTIVE SUMMARY
1
EXECUTIVE SUMMARY
PAIN MANAGEMENT BEST PRACTICES INTERAGENCY TASK FORCE REPORT
BEST PRACTICES
PAIN MANAGEMENT BEST PRACTICES
INTER-AGENCY TASK FORCE REPORT
Updates, Gaps, Inconsistencies, and Recommendations
PAIN MANAGEMENT
FINAL REPORT
2
Submitted by the:
Pain Management Best Practices Inter-Agency Task Force
Report Date:
May 9, 2019
Copyright Information:
All material appearing in this report is in the public domain and may be reproduced or copied.
Suggested Citation:
U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force
Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human
Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html
TABLE OF CONTENTS
iPAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Executive Summary .................................................................................................................................................................................. 1
Task Force Members ................................................................................................................................................................................ 5
Definitions .................................................................................................................................................................................................. 9
1. Introduction ............................................................................................................................................................................................ 11
2. Clinical Best Practices ......................................................................................................................................................................... 17
2.1 Approaches to Pain Management .................................................................................................................................................19
2.1.1 Acute and Chronic Pain ................................................................................................................................................................21
2.1.2 Perioperative Management of Chronic Pain Patients.........................................................................................................23
2.2 Medications ..........................................................................................................................................................................................23
Acetaminophen ............................................................................................................................................................24
NSAIDs ...........................................................................................................................................................................24
Anticonvulsants ............................................................................................................................................................ 24
Antidepressants ...........................................................................................................................................................24
Musculoskeletal Agents ..............................................................................................................................................25
Antianxiety Medications .............................................................................................................................................25
Opioids ........................................................................................................................................................................... 25
2.2.1 Overdose Prevention Education and Naloxone ................................................................................................................... 30
2.3 Restorative Therapies .......................................................................................................................................................................31
Therapeutic Exercise ................................................................................................................................................... 31
Transcutaneous Electric Nerve Stimulation ............................................................................................................32
Massage Therapy.........................................................................................................................................................32
Traction ..........................................................................................................................................................................32
Cold and Heat ...............................................................................................................................................................32
Therapeutic Ultrasound ..............................................................................................................................................32
Bracing ...........................................................................................................................................................................32
2.4 Interventional Procedures ................................................................................................................................................................33
Epidural Steroid Injections .........................................................................................................................................34
Facet Joint Nerve Block and Denervation Injection ..............................................................................................34
Cryoneuroablation .......................................................................................................................................................34
Radiofrequency Ablation ............................................................................................................................................35
Peripheral Nerve Injections ........................................................................................................................................ 35
Sympathetic Nerve Blocks .........................................................................................................................................35
Neuromodulation .........................................................................................................................................................35
Intrathecal Medication Pumps ................................................................................................................................... 35
Vertebral Augmentation .............................................................................................................................................35
Trigger Points ................................................................................................................................................................35
Joint Injections .............................................................................................................................................................36
Interspinous Process Spacer Devices ......................................................................................................................36
Regenerative/Adult Autologous Stem Cell Therapy .............................................................................................36
TABLE OF CONTENTS
ii PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
2.5 Behavioral Health Approaches .......................................................................................................................................................37
Behavioral Therapy .....................................................................................................................................................38
Cognitive Behavioral Therapy ...................................................................................................................................38
Acceptance and Commitment Therapy ................................................................................................................... 38
Mindfulness-Based Stress Reduction ......................................................................................................................38
Emotional Awareness and Expression Therapy .....................................................................................................38
Self-regulatory or Psychophysiological Approaches ............................................................................................38
2.5.1 Access to Psychological Interventions ....................................................................................................................................39
2.5.2 Patients with Chronic Pain as well as Mental Health and Substance Use Comorbidities .....................................40
2.6 Complementary and Integrative Health .......................................................................................................................................41
Acupuncture .................................................................................................................................................................43
Massage and Manipulative Therapies .....................................................................................................................43
MBSR .............................................................................................................................................................................. 43
Yoga ................................................................................................................................................................................ 43
Tai chi .............................................................................................................................................................................43
Spirituality......................................................................................................................................................................44
2.7 Special Populations ............................................................................................................................................................................44
2.7.1 Unique Issues Related to Pediatric Pain Management ...................................................................................................... 44
2.7.2 Older Adults ......................................................................................................................................................................................45
2.7.3 Patients with Cancer-Related Pain and Patients in Palliative Care ................................................................................46
2.7.4 Unique Issues Related to Pain Management in Women ...................................................................................................46
2.7.5 Pregnancy..........................................................................................................................................................................................47
2.7.6 Chronic Relapsing Pain Conditions ........................................................................................................................................... 47
2.7.7 Sickle Cell Disease ......................................................................................................................................................................... 48
2.7.8 Health Disparities in Racial and Ethnic Populations, Including African-Americans, Hispanics/Latinos,
American Indians, and Alaska Natives .................................................................................................................................... 49
2.7.9 Military Active Duty, Reserve Service Members, and Veterans .......................................................................................50
3. Cross-Cutting Clinical and Policy Best Practices ........................................................................................................................... 53
3.1 Risk Assessment .................................................................................................................................................................................53
3.1.1 Prescription Drug Monitoring Programs ..................................................................................................................................53
3.1.2 Screening and Monitoring ............................................................................................................................................................55
3.2 Stigma ....................................................................................................................................................................................................56
3.3 Education ..............................................................................................................................................................................................59
3.3.1 Public Education .............................................................................................................................................................................. 59
3.3.2 Patient Education ............................................................................................................................................................................60
3.3.3 Provider Education .........................................................................................................................................................................61
3.3.4 Policymaker, Regulator, and Legislator Education ............................................................................................................... 62
3.4 Access to Pain Care ...........................................................................................................................................................................62
3.4.1 Medication Shortage .....................................................................................................................................................................63
3.4.2 Insurance Coverage for Complex Management Situations .............................................................................................64
3.4.3 Workforce...........................................................................................................................................................................................65
3.4.4 Research ............................................................................................................................................................................................66
TABLE OF CONTENTS
iiiPAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
4. Review of the CDC Guideline ............................................................................................................................................................. 69
Federal Resources Center ....................................................................................................................................................................... 73
Acronyms ................................................................................................................................................................................................... 79
References ................................................................................................................................................................................................. 83
LIST OF FIGURES
Figure 1: Percentage of Suicide Decedents with Chronic Pain Aged 10 Years or Older, by Year, in 18 States .............................12
Figure 2: The Pain Management Best Practices Report was Framed by Congressional Legislation and Informed by
Task Force Expertise .......................................................................................................................................................................14
Figure 3: Comparison of the 90-Day Comment Period to Public Comment Periods 1 and 2 ...........................................................15
Figure 4: Acute and Chronic Pain Management Consists of Five Treatment Approaches Informed by Four Critical Topics ....19
Figure 5: The Biopsychosocial Model of Pain Management ...................................................................................................................20
Figure 6: Individualized Patient Care Consists of Diagnostic Evaluation That Results in an Integrative Treatment Plan That
Includes All Necessary Treatment Options ........................................................................................................................................ 21
Figure 7: Medication Is One of Five Treatment Approaches to Pain Management ............................................................................23
Figure 8: Medication Approaches Include Opioid and Non-opioid Options ........................................................................................24
Figure 9: Value of Poison Control Centers ..................................................................................................................................................30
Figure 10: Restorative Therapies Are One of Five Treatment Approaches to Pain Management.....................................................31
Figure 11: Interventional Procedures Are One of Five Treatment Approaches to Pain Management .............................................33
Figure 12: Interventional Procedures Vary by Degree of Complexity and Invasiveness .....................................................................34
Figure 13: Behavioral Health Is One of Five Treatment Approaches to Pain Management ................................................................37
Figure 14: Overcoming Barriers to Behavioral Health Approaches ................................................................................................................ 39
Figure 15: Complementary and Integrative Health Is One of Five Treatment Approaches to Pain Management .......................... 41
Figure 16: Complementary and Integrative Health Approaches for the Treatment or Management of Pain Conditions
Consist of a Variety of Interventions ..................................................................................................................................................... 43
Figure 17: A Risk Assessment Is Critical to Providing the Best Possible Patient-Centered Outcome While Mitigating
Unnecessary Opioid Exposure ............................................................................................................................................................... 53
Figure 18: Public Comments to the Task Force Arm the Barriers Stigma Creates ............................................................................57
Figure 19: Education Is Critical to the Delivery of Eective, Patient-Centered Pain Care and Reducing the Risk Associated
With Prescription Opioids ..............................................................................................................................................................59
iv PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
EXECUTIVE SUMMARY
1
EXECUTIVE SUMMARY
PAIN MANAGEMENT BEST PRACTICES INTERAGENCY TASK FORCE REPORT
Patients with acute and chronic pain in the United States face a crisis because of significant challenges in obtaining
adequate care, resulting in profound physical, emotional, and societal costs. According to the Centers for Disease Control
and Prevention, 50 million adults in the United States have chronic daily pain, with 19.6 million adults experiencing high-
impact chronic pain that interferes with daily life or work activities. The cost of pain to our nation is estimated at between
$560 billion and $635 billion annually. At the same time, our nation is facing an opioid crisis that, over the past two
decades, has resulted in an unprecedented wave of overdose deaths associated with prescription opioids, heroin, and
synthetic opioids.
The Pain Management Best Practices Inter-Agency Task Force (Task Force) was convened by the U.S. Department of
Health and Human Services in conjunction with the U.S. Department of Defense and the U.S. Department of Veterans
Aairs with the Oce of National Drug Control Policy to address acute and chronic pain in light of the ongoing opioid
crisis. The Task Force mandate is to identify gaps, inconsistencies, and updates and to make recommendations for best
practices for managing acute and chronic pain. The 29-member Task Force included federal agency representatives as
well as nonfederal experts and representatives from a broad group of stakeholders. The Task Force considered relevant
medical and scientific literature and information provided by government and nongovernment experts in pain management,
addiction, and mental health as well as representatives from various disciplines. The Task Force also reviewed and
considered patient testimonials and public meeting comments, including approximately 6,000 comments from the public
submitted during a 90-day public comment period and 3,000 comments from two public meetings.
The Task Force emphasizes the importance of individualized patient-centered care in the diagnosis and treatment
of acute and chronic pain. This report is broad and deep and will have sections that are relevant to dierent groups of
stakeholders regarding best practices. See the table of contents and the sections and subsections of this broad report to
best identify that which is most useful for the various clinical disciplines, educators, researchers, administrators, legislators,
and other key stakeholders.
The report emphasizes the development of an eective pain treatment plan after proper evaluation to establish a diagnosis,
with measurable outcomes that focus on improvements, including quality of life (QOL), improved functionality, and
activities of daily living (ADLs). Achieving excellence in acute and chronic pain care depends on the following:
• An emphasis on an individualized, patient-centered approach for diagnosis and treatment of pain is essential to establishing
a therapeutic alliance between patient and clinician.
• Acute pain can be caused by a variety of conditions, such as trauma, burn, musculoskeletal injury, and neural injury, as well as
pain from surgery/procedures in the perioperative period. A multimodal approach that includes medications, nerve blocks,
physical therapy, and other modalities should be considered for acute pain conditions.
• A multidisciplinary approach for chronic pain across various disciplines, using one or more treatment modalities, is
encouraged when clinically indicated to improve outcomes. These include the following five broad treatment categories,
which have been reviewed with an identification of gaps/inconsistencies and recommendations for best practices:
• Medications: Various classes of medications, including non-opioids and opioids, should be considered for use. The
choice of medication should be based on the pain diagnosis, the mechanisms of pain, and related co-morbidities
following a thorough history, physical exam, other relevant diagnostic procedures and a risk-benefit assessment that
demonstrates that the benefits of a medication outweigh the risks. The goal is to limit adverse outcomes while
ensuring that patients have access to medication-based treatment that can enable a better QOL and function. Ensuring
safe medication storage and appropriate disposal of excess medications is important to ensure best clinical outcomes
and to protect the public health.
2 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
EXECUTIVE SUMMARY
• Restorative Therapies, including those implemented by physical therapists and occupational therapists (e.g.,
physiotherapy, therapeutic exercise, and other movement modalities) are valuable components of multidisciplinary,
multimodal acute and chronic pain care.
• Interventional Approaches, including image-guided and minimally invasive procedures, are available as diagnostic and
therapeutic treatment modalities for acute, acute on chronic, and chronic pain when clinically indicated. A list of various
types of procedures, including trigger point injections, radio-frequency ablation, cryo-neuroablation, neuromodulation,
and other procedures are reviewed.
• Behavioral Approaches for psychological, cognitive, emotional, behavioral, and social aspects of pain can have a
significant impact on treatment outcomes. Patients with pain and behavioral health comorbidities face challenges that
can exacerbate painful conditions as well as function, QOL, and ADLs.
• Complementary and Integrative Health, including treatment modalities such as acupuncture, massage, movement
therapies (e.g., yoga, tai chi), and spirituality, should be considered when clinically indicated.
• Eective multidisciplinary management of the potentially complex aspects of acute and chronic pain should be based on a
biopsychosocial model of care.
• Health systems and clinicians must consider the pain management needs of the special populations that are confronted
with unique challenges associated with acute and chronic pain, including the following: children/youth, older adults, women,
pregnant women, individuals with chronic relapsing pain conditions such as sickle cell disease, racial and ethnic populations,
active duty military and reserve service members and Veterans, and patients with cancer who require palliative care.
• Risk assessment is one of the four cross-cutting policy approaches necessary for best practices in providing individualized,
patient-centered care. A thorough patient assessment and evaluation for treatment that includes a risk-benefit analysis are
important considerations when developing patient-centered treatment. Risk assessment involves identifying risk factors from
patient history; family history; current biopsychosocial factors; and screening and diagnostic tools, including prescription drug
monitoring programs, laboratory data, and other measures. Risk stratification for a particular patient can aid in determining
appropriate treatments for the best clinical outcomes for that patient. The final report and this section in particular emphasize
safe opioid stewardship, with regular reevaluation of the patient.
• Stigma can be a barrier to treatment of painful conditions. Compassionate, empathetic care centered on a patient-clinician
relationship is necessary to counter the suering of patients with painful conditions and to address the various challenges
associated with the stigma of living with pain. Stigma often presents a barrier to care and is often cited as a challenge for
patients, families, caregivers, and providers.
• Improving education about pain conditions and their treatment for patients, families, caregivers, clinicians, and policymakers
is vital to enhancing pain care. Patient education can be emphasized through various means, including clinician discussion,
informational materials, and web resources. More eective education and training about acute and chronic pain should occur
at all levels of clinician training, including undergraduate educational curricula, graduate professional training, and continuing
professional education, with the use of proven innovations such as the Extension for Community Healthcare Outcomes
(Project ECHO) model. Education for the public as well as for policymakers and legislators is emphasized to ensure that
expert and cutting-edge understanding is part of policy that can aect clinical care and outcomes.
• Addressing barriers to access to care is essential in optimizing pain care. Recommendations include addressing the gap in
our workforce for all disciplines involved in pain management. In addition, improved insurance coverage and payment for
dierent pain management modalities is critical to improving access to eective clinical care and should include coverage
and payment for care coordination, complex opioid management, and telemedicine. It is also important to note that in many
parts of the country, patients have access only to a primary care provider (PCP). Support for education, time, and financial
resources for PCPs is essential to managing patients who have painful conditions.
• Research and Development: Continued medical and scientific research is critical to understanding the mechanisms
underlying the transition from acute to chronic pain; to translating promising scientific advances into new and
eective diagnostic, preventive and therapeutic approaches for patients; and to implementing these approaches
eectively in health systems.
3PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
EXECUTIVE SUMMARY
A review of the CDC Guideline (as mandated by the Comprehensive Addiction and Recovery Act legislation): The Task Force
recognizes the utility of the 2016 Guideline for Prescribing Opioids for Chronic Pain released by the CDC and its contribution
to mitigating unnecessary opioid exposure and the adverse outcomes associated with opioids. It also recognizes unintended
consequences that have resulted following the release of the guidelines in 2016, which are due in part to misapplication or
misinterpretation of the guideline, including forced tapers and patient abandonment. The CDC recently published a pivotal
article in the New England Journal of Medicine on April 24, 2019, specifically reiterating that the CDC Guideline has been,
in some instances, misinterpreted or misapplied.
1
The authors highlight that the guideline does not address or suggest
discontinuation of opioids prescribed at higher dosages. They note, “policies invoking the opioid-prescribing guideline that
do not actually reflect its content and nuances can be used to justify actions contrary to the guideline’s intent.” Educating
stakeholders about the intent of the guideline (as it relates to the use of opioids for chronic pain by primary care clinicians),
reemphasis of the core benefits of the guideline, and encouraging optimal application of this guideline are essential to
optimizing acute and chronic pain care. (Please see Section 4: Review of the CDC Guideline in the attached Task Force report).
The Task Force, which included a broad spectrum of stakeholder perspectives, was convened to address one of the
greatest public health crises of our time. The Task Force respectfully submits these gaps and recommendations, with special
acknowledgement of the brave individuals who have told their stories about the challenges wrought by pain in their lives, the
thousands of members of the public and organizations sharing their various perspectives and experiences through public
comments, and the millions of others they represent in our nation who have been aected by pain.
4 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
EXECUTIVE SUMMARY
The illustration above was generated by collecting public comments from docket HHS-OS-2018-0027, received as of March 21, 2019, from the Regulations.gov
application programming interface and processed using Booz Allen’s proprietary Vernacular-to-Regulatory classifiers, which annotate natural language texts
with codes from the Medical Dictionary of Regulatory Aairs (MedDRA). MedDRA’s lowest level terms (LLTs) were extracted from those annotations, processed
into a frequency table, and visualized using the open source wordcloud Python software package; word size magnitude adjusted per qualitative review and
discussion by the Task Force.
TASK FORCE MEMBERS
5PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
The Pain Management Best Practices Inter-Agency Task Force consists of 29 members — 12 public members, nine organization
representative members, and eight federal members — based on criteria specified in the Comprehensive Addiction and
Recovery Act of 2016.
CHAIR
Vanila M. Singh, M.D., MACM
Chief Medical Ocer, Oce of the Assistant Secretary for Health, U.S. Department of Health and Human Services.
SPECIAL GOVERNMENT EMPLOYEE MEMBERS
Sondra M. Adkinson, Pharm.D.
Clinical Pharmacist, Bay Pines Veterans Administration Healthcare System, Bay Pines, Florida.
Amanda Brandow, D.O., M.S.
Associate Professor of Pediatrics in Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
Daniel Clauw, M.D.
Director, Chronic Pain and Fatigue Research Center; Professor of Anesthesiology, Medicine (Rheumatology) and Psychiatry,
University of Michigan, Ann Arbor, Michigan.
Howard L. Fields, M.D., Ph.D.
Professor Emeritus, Departments of Neurology and Physiology, University of California San Francisco, San Francisco, California.
Rollin M. Gallagher, M.D., M.P.H.
Editor-in-Chief, Pain Medicine, and Emeritus Investigator, Center for Health Equities Research and Promotion Corporal Michael J.
Crescenz VA Medical Center, Philadelphia, Pennsylvania.
Halena M. Gazelka, M.D.
Assistant Professor of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Sciences; Chair,
Mayo Clinic Opioid Stewardship Program; and Director of Inpatient Pain Services, Division of Pain Medicine, Mayo Clinic,
Rochester, Minnesota.
Nicholas E. Hagemeier, Pharm.D., Ph.D.
Associate Professor of Pharmacy Practice, Gatton College of Pharmacy, East Tennessee State University (ETSU); Research
Director, ETSU Center for Prescription Drug Abuse Prevention and Treatment, Johnson City, Tennessee.
John J. McGraw, Sr., M.D.
Medical Director, OrthoTennessee; County Commissioner, Jeerson County, Tennessee.
John V. Prunskis, M.D.
Founder, Co-Medical Director, Illinois Pain Institute, Elgin, Illinois.
TASK FORCE MEMBERS
6 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Molly Rutherford, M.D., M.P.H.
Certified Addiction Specialist, Founder, Bluegrass Family Wellness, PLLC, Crestwood, Kentucky.
Bruce A. Schoneboom, Ph.D.
Associate Dean for Practice, Innovation and Leadership, Johns Hopkins School of Nursing, Baltimore, Maryland.
Harold K. Tu, M.D., D.M.D.
Associate Professor and Director, Division of Oral and Maxillofacial Surgery, School of Dentistry, University of Minnesota; Chair,
Department of Dentistry, Fairview Hospital, University of Minnesota Medical School, Minneapolis, Minnesota.
REPRESENTATIVE MEMBERS
René Campos, Retired U.S. Navy, Commander
Senior Director of Government Relations, Military Ocers Association of America, Alexandria, Virginia.
Jianguo Cheng, M.D., Ph.D.
Professor of Anesthesiology, Director of the Cleveland Clinic Multidisciplinary Pain Medicine Fellowship Program, Cleveland,
Ohio; and President, American Academy of Pain Medicine.
Jonathan C. Fellers, M.D.
Medical Director, Integrated Medication-Assisted Therapy, Maine Medical Center; Medical Director, Maine Tobacco Help Line,
MaineHealth Center for Tobacco Independence, Portland, Maine.
Michael J. Lynch, M.D.
Medical Director, Pittsburgh Poison Center; Assistant Professor, University of Pittsburgh, Department of Emergency Medicine,
Pittsburgh, Pennsylvania.
Mary W. Meagher, Ph.D.
Professor and Coordinator of the Clinical Health Psychology Program at Texas A&M, College Station, Texas.
Mark Rosenberg, D.O., M.B.A.
Chair, Emergency Medicine, and Chief Innovation Ocer, St. Joseph’s Health; Board of Directors, American College Emergency
Physicians, Paterson, New Jersey.
Cindy Steinberg
National Director, Policy and Advocacy, U.S. Pain Foundation; Policy Council Chair, Massachusetts Pain Initiative, Lexington,
Massachusetts.
Andrea Trescot, M.D.
Interventional Pain Physician; Director, Pain and Headache Center, Eagle River, Alaska.
Sherif Zaafran, M.D.
President, Texas Medical Board, Austin, Texas.
FEDERAL MEMBERS
Steve Daviss, M.D.
Senior Medical Advisor for Oce of the Chief Medical Ocer; Medical Director for Center for Substance Abuse Treatment;
Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. (May 30, 2018 to
Aug. 1, 2018).
Scott Grith, M.D.
Director, National Capital Region Pain Initiative, and Program Director, National Capital Consortium Pain Medicine Fellowship,
U.S. Department of Defense.
TASK FORCE MEMBERS
7PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Sharon Hertz, M.D.
Director, Division of Anesthesia, Analgesia, and Addiction Products, Center for Drug Evaluation and Research, U.S. Food and
Drug Administration, U.S. Department of Health and Human Services.
Jan L. Losby, Ph.D.
Lead, Opioid Overdose Health Systems Team, Division of Unintentional Injury Prevention, Centers for Disease Control and
Prevention, U.S. Department of Health and Human Services.
Capt. Chideha M. Ohuoha, M.D.
Director, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, U.S. Department
of Health and Human Services. (May 30, 2018 to Dec. 31, 2018).
Linda L. Porter, Ph.D.
Director, Oce of Pain Policy, National Institute for Neurological Disorders and Stroke, National Institutes of Health, U.S.
Department of Health and Human Services.
Friedhelm Sandbrink, M.D.
National Program Director, Pain Management Specialty Care Services, Veterans Administration Health System; Director, Pain
Management Program, Department of Neurology, U.S. Department of Veterans Aairs.
Cecelia Spitznas, Ph.D.
Senior Science Policy Advisor, Oce of the Director, Oce of National Drug Control Policy.
DESIGNATED FEDERAL OFFICER
Alicia Richmond Scott, M.S.W.
Senior Policy Analyst, Oce of the Assistant Secretary for Health, U.S. Department of Health and Human Services.
ACKNOWLEDGEMENTS
The Task Force Chair, Dr. Vanila Singh, M.D., MACM would like to give a special acknowledgement to the eorts of the
individuals noted below:
• Drs. Molly Rutherford, M.D., M.P.H., Rollin M. Gallagher, M.D., M.P.H., and Sherif Zaafran, M.D., for their additional time and
contribution as Subcommittee Chairs.
• Dr. Peter Staats, M.D., for providing his expertise to the Subcommittee One discussions.
• Dr. Robert Bonakdar, M.D., Scripps Center for Integrative Medicine; RADM Michael Toedt, M.D., Chief Medical Ocer, Indian
Health Service, U.S. Department of Health and Human Services; and Dr. Shari M. Ling, M.D., Deputy Chief Medical Ocer,
Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services, for providing their areas of
expertise to the Subcommittees.
• The Oce of the Assistant Secretary for Health’s Chief Medical Ocer, Dr. Singh’s sta: Alicia Richmond Scott, M.S.W., Task
Force Designated Federal Ocer and Senior Public Health Advisor; Chanya Liv, Public Health Advisor; Monica Stevenson,
Executive Assistant; LCDR Rachel Katonak, Ph.D., R.N., Nurse Ocer, U.S. Public Health Service and Public Health Analyst;
and Joshua Montgomery, M.P.H., ORISE Fellow, for their hard work and support.
DEFINITIONS
9PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Physical dependence is not the same as addiction and occurs because of physiological adaptations to chronic exposure to a
drug. Someone who is physically dependent on medication will experience withdrawal symptoms when the use of the medicine
is suddenly reduced or stopped or when an antagonist to the drug is administered. These symptoms can be minor or severe
and can usually be managed medically or avoided by using a slow drug taper.
2,3
Tolerance is present when the same dose of a drug when given repeatedly produces a reduced biological response. Stated
another way, it takes a higher dose of the drug to achieve the same level of response achieved initially.
2,3
Misuse of prescription drugs means taking a medication in a manner or dose other than prescribed; taking someone else’s
prescription, even if for a medical complaint such as pain; or taking a medication to feel euphoria (i.e., to get high). The term
nonmedical use of prescription drugs also refers to these categories of misuse.
2,3
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual
pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability
to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s
behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often
involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and
can result in disability or premature death.
4
Opioid use disorder (OUD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as a
problematic pattern of opioid use leading to clinically significant impairment or distress. OUD was previously classified as Opioid
Abuse or Opioid Dependence in DSM-IV. OUD has also been referred to as “opioid addiction.”
Hyperalgesia is a condition where patients have a hypersensitivity to pain caused by pain medications. Healthcare providers
may consider opioid induced hyperalgesia when an opioid treatment eect dissipates and other explanations for the increase in
pain are absent, particularly if found in the setting of increased pain severity coupled with increasing dosages of an analgesic.
2,3
1
INTRODUCTION
11PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
The experience of pain has been recognized as a national public health problem with profound physical, emotional, and societal
costs.
5
Although estimates vary depending on the methodology used to assess pain, it is estimated that chronic pain aects
50 million U.S. adults, and 19.6 million of those adults experience high-impact chronic pain that interferes with daily life or work
activities.
6
The cost of pain to our nation is estimated at between $560 billion and $635 billion annually.
7
Pain management
stakeholders have been working to improve care for those suering from acute and chronic pain in an era challenged by the
opioid crisis.
8
An unprecedented rise in the number of deaths from overdose in the past two decades is associated with prescription opioids,
heroin, and synthetic opioids.
9
The practice of pain management and the opioid crisis have influenced one another as each has
evolved in response to dierent influences and pressures. It is imperative to ensure that patients with painful conditions can
work with their health care providers to develop integrative pain treatment plans that balance a focus on optimizing function,
quality of life (QOL), and productivity while minimizing risks for opioid misuse and harm.
“The ongoing opioid crisis lies at the intersection of two substantial public health challenges — reducing
the burden of suering from pain and containing the rising toll of the harms that can result from the use
of opioid medications.”
– Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and
Risks of Prescription Opioid Use; National Academies of Sciences, Engineering, and Medicine, 2017.
This report is the product of the Pain Management Best Practices Inter-Agency Task Force (Task Force) and is intended to guide
the public at large, federal agencies, and private stakeholders. The field of pain management began to undergo significant
changes in the 1990s, when pain experts recognized that inadequate assessment and treatment of pain had become a
public health issue.
5
Recommendations for improving the quality of pain care
10
were followed by initiatives that recognized
patients’ reported pain scores as “The 5th Vital Sign.”
11
Hospital administrators and regulators began to focus on pain scores,
encouraging and incentivizing clinicians to aggressively treat pain to lower pain scores. In addition, increasing administrative
burdens (e.g., required quality measures, electronic health records [EHRs], data management, and government regulation
requirements) led to less time for direct patient care. The administrative burden of using EHRs has contributed significantly to
physicians’ burnout, likely aecting their capacity to manage the complexity of pain care.
12–14
As the mandate for improved pain
management has increased, there was and is a need for better education and training of clinicians as well as more time and
resources to respond to the unmet needs of patients with painful conditions.
8,15
It is also important to note that in many parts of
the country, patients have access only to their primary care provider (PCP). Support for education, time, and financial resources
for PCPs is essential to managing patients with painful conditions.
Converging eorts to improve pain care led to an increased use of opioids in the late 1990s through the first decade of the 21st
century.
16
These initiatives included an overall eort for lowering pain scores, the more liberal use of opioids, and the aggressive
marketing of new opioid formulations coupled with the continued limited coverage of non-opioid options. These trends resulted
in a liberalization of opioid prescribing.
3,11
Prescription opioids can and are used to treat acute and chronic pain and are often
prescribed following surgery or injury and for a subset of patients with chronic pain from medical conditions such as cancer
and inflammatory, neurological, and musculoskeletal conditions. Multidisciplinary and multimodal approaches to acute and
chronic pain are often not supported with time and resources, leaving clinicians with few options to treat often challenging and
complex underlying conditions that contribute to pain severity and impairment. As medical and policymaking organizations
began to urge caution about the use of opioids for pain, the federal government has developed a multifaceted approach to the
1. INTRODUCTION
12 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
opioid epidemic, including the U.S. Department of Health and Human Services (HHS) 5-Point Strategy to Combat the Opioid
Crisis.
17
In addition, various eorts now address this public health problem across federal, state, and local governments as
well as the community, private, and academic sectors, including the “Initiative to Stop Opioid Abuse and Reduce Drug Supply
and Demand,” issued in 2018 by President Donald J. Trump. A public health emergency was declared in October 2017 and
subsequently renewed as a result of the continued consequences of the opioid crisis.
Significant public awareness through education and guidelines from regulatory and government agencies and other stakeholders
to address the opioid crisis have in part resulted in reduced opioid prescriptions. Regulatory oversight has also led to fears
of prescribing among clinicians, with some refusing to prescribe opioids even to established patients who report relief and
demonstrate improved function on a stable opioid regimen.
18
The Centers for Disease Control and Prevention published a pivotal
article in the New England Journal of Medicine (NEJM) on April 24, 2019, specifically reiterating that the 2016 Guideline for
Prescribing Opioids for Chronic Pain (CDC Guideline) has been, in some instances, misinterpreted or misapplied.
1
This increased
vigilance of prescription opioids and the tightening of their availability have in some situations led to unintended consequences,
such as patient abandonment and forced tapering. Some established patients with pain may transition to using illicit drugs for
pain control, including illicit fentanyl and heroin — a separate group of patients distinguishable from those with substance use
disorders (SUDs) (as evidenced by Task Force public comments). The CDC has recently noted that the opioid crisis is quickly
moving to a fentanyl crisis.
19
This has coincided with an increase in the demand for illicit synthetic opioids as well as other
substances,
20,21
including a four-fold increase in the rate of death from heroin since 2010.
22
Nationwide, nearly half of all opioid
overdose deaths in 2017 involved illicitly manufactured fentanyl. Fentanyl is an opioid 50 times more potent than morphine. Illicit
fentanyl (manufactured abroad and distinct from commercial medical fentanyl approved for pain and anesthesia in the United
States) is a potent synthetic opioid. Illicit fentanyl is sometimes mixed with other drugs (prescription opioids and illicit opioids, such
as heroin, and other illegal substances, including cocaine) that further increase the risk of overdose and death.
A significant number of public comments submitted to the Task Force shared growing concerns regarding suicide due to pain
as well as a lack of access to treatment. According to a recent CDC report using data from the National Violent Death Reporting
System, the percentage of people who died by suicide and had evidence of chronic pain increased from 7.4% in 2003 to 10.2%
in 2014.
23
Numbers from this data set beyond 2014 are not yet available. These findings are made more concerning when one
considers the rising trend of health care professionals opting out of treating pain, thus exacerbating an existing shortage of pain
management specialists,
5
leaving a vulnerable population without adequate access to care.
Data from National Violent Death Reporting System (NVDRS). Limitations: Data is not nationally representative because the number of states involved varied, so
this was not nationally representative. In addition, “chronic pain” is not a standard variable that NVDRS collects and therefore is limited by the lack of pre-event
information. Certain diagnoses were assumed to indicate chronic pain, and assumption of this study erred on the side of undercounting chronic pain.
Year of Death
Percentage of Suicide Decedents Aged 10 Years or Older
2003 2013201220112010200920082007200620052004 2014
12.00
10.00
8.00
6.00
4.00
2 .00
0.00
Suicide decedents with chronic pain
Suicide decedents with chronic pain who died by opioid overdoes
Data from National Violent Death Reporting System (NVDRS). Limitations: Data is not nationally representative
because the number of states involved varied, so this was not nationally representative. In addition, “chronic
pain” is not a standard variable that NVDRS collects and therefore is limited by the lack of pre-event
information. Certain diagnoses were assumed to indicate chronic pain, and assumption of this study erred on
the side of undercounting chronic pain.
Figure 1: Percentage of Suicide Decedents With Chronic Pain Aged 10 Years or Older, by Year, in 18 States
Year of Death
Percentage of Suicide Decedents Aged 10 Years or Older
2003 2013201220112010200920082007200620052004 2014
12.00
10.00
8.00
6.00
4.00
2 .00
0.00
Suicide decedents with chronic pain
Suicide decedents with chronic pain who died by opioid overdoes
Data from National Violent Death Reporting System (NVDRS). Limitations: Data is not nationally representative
because the number of states involved varied, so this was not nationally representative. In addition, “chronic
pain” is not a standard variable that NVDRS collects and therefore is limited by the lack of pre-event
information. Certain diagnoses were assumed to indicate chronic pain, and assumption of this study erred on
the side of undercounting chronic pain.
Figure 1: Percentage of Suicide Decedents With Chronic Pain Aged 10 Years or Older, by Year, in 18 States
1. INTRODUCTION
1313PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Comprehensive pain management can be a challenge for various reasons. In the current environment, patients with chronic
pain — particularly those being treated with opioids — can be stigmatized, a tendency exacerbated when their pain condition
is complicated by mental health co-morbidities such as anxiety and depression or by SUDs. Because opioids can produce
opioid use disorder (OUD) in at-risk populations, risk assessment and periodic reevaluation and monitoring are required for
all patients in these populations and should be a part of the complex care management they need, particularly when there is
an intersection of chronic pain, opioids, mental health, and addiction. There is strong evidence that because of awareness of
and education about these issues, prescription opioid misuse has been decreasing, from 12.8 million individuals in 2015 to 11.4
million individuals in 2017.
24
HHS is advancing a comprehensive approach that addresses improved pain management in both the acute and chronic pain
setting. This eort is part of the 5-Point Strategy to Combat the Opioid Crisis.
17
This work includes execution of mandates set
forth by the Comprehensive Addiction and Recovery Act (CARA), which establishes “an interagency task force, convened
by HHS, in conjunction with the Department of Defense (DoD), the Department of Veterans Aairs (VA), and the Executive
Oce of the President’s Oce of National Drug Control Policy.”
25
The CARA legislation instructs the Task Force to “determine
whether there are gaps in or inconsistencies between best practices for pain management” and “propose updates to best
practices and recommendations on addressing gaps or inconsistencies.”
25
The Task Force recognizes that comprehensive pain management often requires the work of various health care
professionals, including physicians of various disciplines, dentists, nurses, nurse practitioners (NPs), physician assistants
(PAs), pharmacists, physical therapists, occupational therapists, behavioral health specialists, psychologists, social workers,
and integrative health practitioners. The complexity of some pain conditions requires multidisciplinary coordination among
health care professionals; in addition to the direct consequences of acute and chronic pain, the experience of pain can
exacerbate other health issues, including delayed recovery from surgery or worsen behavioral and mental health disorders.
Achieving excellence in patient-centered care depends on a strong patient-clinician relationship defined by mutual trust and
respect, empathy, and compassion, resulting in a strong therapeutic alliance.
26
As required by congressional legislation, HHS
has convened the Task Force, which consists of 29 members who have expertise in pain management, patient advocacy,
addiction, mental health, and minority health as well as other organizational representatives from state medical boards and
Veteran service organizations, among others. The Task Force also includes representatives from federal agencies, including
HHS, VA, DoD, and the Oce of National Drug Control Policy.
1. INTRODUCTION
14 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Specialty
Expertise
• Pain Management
• Substance Use Disorders
• Mental Health
• Minority Health
• Patient Advocacy
• Primary Care
• Pharmacists
• Surgeons
• Dental Specialists
• Toxicology
• Emergency Medicine
Non-Federal
Organizations
• Hospital Associations
• Patient Advocacy
Organizations
• Professional Medical
Organizations
• State Medical Boards
• Veteran Service
Organizations
Federal
Organizations
• Department of Health
and Human Services
• Department of
Veterans Aairs
• Department of Defense
• Executive Oce of the
President – Oce of National
Drug Control Policy
Pain Management Inter-Agency Task Force Members
2016 Comprehensive Addiction & Recovery Act
Establish a Task Force to identify, review, and, as appropriate, determine whether there are
gaps in or inconsistencies between best practices for pain management (including chronic
and acute pain) developed or adopted by Federal agencies
Figure 2: The Pain Management Best Practices Report Was Framed by Congressional
Legislation and Informed by Task Force Expertise
In 2018, the Task Force convened two public meetings that included extensive public comments and critical patient testimonials
from various patient groups, including various special population presentations. The Task Force reviewed and considered public
comments, including approximately 6,000 comments from the public submitted during a 90-day public comment period and 3,000
comments from two public meetings. Presentations to the Task Force included the Indian Health Services (IHS); the Defense Health
Agency; VA ocials; HHS ocials from the National Institute on Drug Abuse, the National Institute on Neurological Disorders and
Stroke, and the U.S. Food and Drug Administration (FDA); state health ocials; private stakeholder organizations; and experts. The
Task Force reviewed extensive public comments, patient testimonials, and existing best practices and considered relevant medical
and scientific literature. Task Force discussion and analysis resulted in the identification of gaps and inconsistencies, updates,
and recommendations for acute and chronic pain management best practices described in this report, consistent with the CARA
legislation. In the context of this report, the term “gap” includes gaps across existing best practices, inconsistencies among existing
best practices, the identification of updates needed to best practices, or a need to reemphasize vital best practices. Gaps and
recommendations in the report span five major treatment modalities that include medication, restorative therapies, interventional
procedures, behavioral health approaches, and complementary and integrative health approaches. This report provides gaps and
recommendations for special populations confronting unique challenges in pain management as well as gaps and recommendations
for critical topics that are broadly relevant across treatment modalities, including stigma, risk assessment, education, and access to
care. The report reviews the CDC Guideline as mandated by the statute.
1. INTRODUCTION
1515PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Figure 3 Legend. Categories (x-axis): Selected topic areas relevant to pain management. Percentage of Mentions (y-axis): The percentage of public comments
within each specified public comment period addressing each category. 90-Day Comment Period Dates: Dec 31, 2018 – April 1, 2019. Public Comment Period 1
and 2 dates, respectively: Apr. 26, 2018 – Jun 15, 2018, Aug. 9, 2018 – Sept. 17, 2018.
Figure 3: Comparison of the 90-Day Comment Period to Public Comment Periods 1 and 2
*Because cannabis, or marijuana, remains a Schedule I drug in the United States and rigorous studies are lacking on the safety
and ecacy of any specific cannabis product as a treatment for pain, the Task Force did not include cannabis as a specific
focus of our recommendations. (According to the U.S. Drug Enforcement Administration [DEA], Schedule I drugs, substances,
or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse; although marijuana/
cannabis is legal for medical use in several states, it is illegal at the federal level.) However, with the increased public interest
in using some forms of cannabis as a means of pain treatment, more research and data are needed to ascertain the risk and
benefits to make recommendations.
27
2
CLINICAL BEST PRACTICES
17PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
In pain management, a critical part of providing comprehensive care is a thorough initial evaluation, including assessment of
both the medical and the probable biopsychosocial factors causing or contributing to a pain condition. A second critical step is to
develop a treatment plan to address the causes of pain and to manage pain that persists despite treatment. Quality pain diagnosis
and management can alter opioid prescribing both by oering alternatives to opioids and by clearly stating when they may be
appropriate.
8
Several recent clinical practice guidelines (CPGs) for best practices for chronic pain management agree on specific
recommendations for mitigating opioid-related risk through risk assessment, including screening for risks (e.g., depression, active or
prior history of SUDs, family history of SUD, childhood trauma) prior to initiating opioids; medication dosing thresholds; consideration
of drug-drug interactions, with specific medications and drug-disease interactions; risk assessment and mitigation (e.g., patient-
provider treatment agreements); drug screening/testing; prescription drug monitoring programs; and access to nonpharmacologic
treatments. Clinical practice guidelines for best practices that only promote and prioritize minimizing opioid administration run the
risk of undertreating pain, especially when the cause of the pain is uncertain or cannot be reduced through non-opioid approaches.
To continue improving quality of pain care in the current environment of opioid-related risks, experts have noted several key
challenges associated with clinical best practices (CBPs). First, there is the need to increase the use of CPGs, as indicated in specific
patient groups delineated by their underlying diagnosis or cause of pain (e.g., arthritis, postoperative, neuropathic), comorbidities,
psychosocial characteristics (e.g., social support, stress), demographics, and settings (e.g., hospital, perioperative, primary care,
emergency department [ED]). Second, access to eective pain management treatments must be improved through adoption of
clinical best practices in medical and dental practice and clinical health systems.
28
Third, clinical best practices for pain management
should be better incorporated into the routine training of clinicians,
29
with special attention to residency training to meet the needs of
patients treated in each specialty.
8,15
Finally, quality care must be adequately reimbursed.
Pain management experts have also identified specific research gaps that are impeding the improvement of pain management best
practices, including synthesizing and tailoring recommendations across guidelines, diagnoses, and populations. In addition, gaps
and inconsistencies exist within and between pain management and opioid prescribing guidelines.
30–32
This finding is also the result
of demographic and other variances, because CBPs are developed in dierent regions of the country. A recent review of clinical
opioid prescribing guidelines by Barth et al.
33
notes several needs — including the development of postoperative pain management
guidelines for dierent surgical procedures, with the understanding of patient variability in physiology, drug metabolism, and
underlying disease processes. This research further emphasizes the need for an individualized, patient-centered approach
focused on achieving improved function, activities of daily living (ADLs), and QOL as well as pain control. In light of these gaps, pain
management providers should consider potential limitations to evidence-based clinical recommendations.
34
A systematic review of CPGs for neuropathic pain
35
identified shortcomings across four evaluation domains: (1) stakeholder
involvement (i.e., the extent to which the guideline was developed by the appropriate stakeholders and represents the views of its
intended users); (2) the rigor of development (i.e., the process used to gather and synthesize the evidence and the methods used
to formulate the recommendations); (3) applicability (i.e., likely barriers and facilitators to implementation of the guideline, strategies
to improve its uptake, and resource implications of applying it); and (4) editorial independence (i.e., bias in the formulation of the
recommendations), not to mention the knowledge and skill set of the clinician. Identified inconsistencies across guidelines for some
painful conditions, such as fibromyalgia, have demonstrated a need for consensus in guideline development.
36
A review of state-
level guidelines for opioid prescriptions found that a minority of states had guidelines specific to EDs.
37
Pain guidelines from the
World Health Organization (WHO) are facing a lack of adoption, potentially because they lack incorporation of contemporary pain
management practices.
38
2. CLINICAL BEST PRACTICES
18 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
For the past eight years, I have lived with debilitating chronic pain as the result of Klippel-Feil
syndrome, a rare spinal defect. Over the years, I have tried every possible treatment. I’ve
had neurosurgery. I get regular injections, massages, and acupuncture. I do physical therapy
and yoga daily. I wear braces. I buy expensive pillows. I meditate. I eat well. I do all the things
you’re supposed to do.
But I also need medications. For nearly a year after the pain began, I refused to take
anything. I certainly had no interest in taking an opioid. But it was only after eight months of
agonizing trial and error with other drugs that we tried Tramadol, as a last resort, and found
that it worked.
And yet despite taking one of the safest opioids available, and taking it responsibly for a
legitimate problem, I faced restrictions that made me feel more like a criminal than a patient.
Once, a doctor refused to refi ll my Tramadol prescription, even while acknowledging that
I showed no signs of abuse. I ended up in the ER where they told me they could only treat
withdrawal. It was the most horrifi c and dehumanizing experience of my life. Another example
was the time I wanted to consult a second pain specialist about injections. Although I wasn’t
asking for medications, I was berated just for asking for a second opinion and left the
appointment in tears. Most recently, my health insurance suddenly refused to cover Tramadol.
After much back and forth, they wanted proof I had signed an opioid contract. I had in fact
signed one, but the doctor had lost his copy. It took over three weeks to resolve. These
stories may sound like minor inconveniences, but keep in mind what it would be like to deal
with this on top of debilitating pain.
I have sometimes wished I had cancer instead of a spine defect, knowing I would be treated
with more respect and compassion. And let’s not overlook that I am a middle-class Caucasian
female with a strong support system and a background in health care. I cannot imagine
how these restrictions are a ecting people of color, or the elderly, or those from a lower
socioeconomic status.
EMILY’S
STORY
PATIENT TESTIMONIAL
2.1 APPROACHES TO PAIN MANAGEMENT
19PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Acute and Chronic Pain Management:
Individualized, Multimodal, Multidisciplinary
Acute and Chronic Pain Management:
Individualized, Multimodal, Multidisciplinary
Education
Access to Care
Stigma
Risk Assessment
Behavioral
Health
Approaches
Interventional
Procedures
Restorative
Therapies
Medication
Complementary
& Integrative
Health
Figure 4: Acute and Chronic Pain Management Consists of Five
Treatment Approaches Informed by Four Critical Topics
Acute and Chronic Pain Management:
Individualized, Multimodal, Multidisciplinary
Acute and Chronic Pain Management:
Individualized, Multimodal, Multidisciplinary
Education
Access to Care
Stigma
Risk Assessment
Behavioral
Health
Approaches
Interventional
Procedures
Restorative
Therapies
Medication
Complementary
& Integrative
Health
Figure 4: Acute and Chronic Pain Management Consists of Five
Treatment Approaches Informed by Four Critical Topics
Recent clinical practice guidelines developed by the VA and DoD adopt the biopsychosocial model of pain.
32
In this endeavor,
they emphasize a collaborative, stepped care model.
48,49
The biopsychosocial approach is applied clinically across pain
experiences, including chronic pain,
50
and specifically to musculoskeletal pain,
51
low-back pain,
52,53
and HIV-related pain.
54
The
development of a treatment plan should be preceded by a history and physical examination that aids in proper diagnosis. When
clinically indicated, clinicians should consider an integrative and collaborative approach to care. Specialty interdisciplinary pain
medicine team consultation, collaborative care, and (when indicated) mental health and addiction services should be readily
available in the course of treatment of pain to help ensure the best patient outcomes. Medical organizations and advocacy
groups are encouraged to be involved in the development of clinical practice guidelines for the treatment of particular pain
conditions. When clinically indicated, these CPGs can be used within the context of the multimodal and multidisciplinary
approach to pain care.
2.1 APPROACHES TO PAIN MANAGEMENT
A multimodal approach to pain management consists of using treatments from one or more clinical disciplines incorporated
into an overall treatment plan. This plan allows for dierent approaches to address the pain condition (acute and/or chronic),
often enabling a synergistic approach that addresses the dierent aspects of the pain condition, including functionality.
Multidisciplinary approaches address dierent aspects of chronic pain conditions, including biopsychosocial eects of the
medical condition on the patient.
39–41
The ecacy of such a coordinated, integrated approach has been documented to reduce
pain severity, improve mood and overall QOL, and increase function.
40,42–47
2.1 APPROACHES TO PAIN MANAGEMENT
20 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Mood/aect
Stress
Coping
Trauma
Childhood
P
s
y
c
h
o
l
o
g
i
c
a
l
F
a
c
t
o
r
s
B
i
o
l
o
g
i
c
a
l
F
a
c
t
o
r
s
Pain generator
Precise diagnosis
Age
Injury/past injury
Illness/diagnosis
Neurologic
Genetic
Hormones
Obesity
Cultural factors
Economic factors
Social support
Spirituality
Ethnicity
Education
Bio/stigma
S
o
c
i
a
l
F
a
c
t
o
r
s
PAIN
Figure 5: The Biopsychosocial Model of Pain Management
GAPS AND RECOMMENDATIONS
GAP 1: Current inconsistencies and fragmentation of pain care limit best practices and patient outcomes. A coherent policy for
pain management for all relevant stakeholders is needed.
RECOMMENDATION 1A: Encourage coordinated and collaborative care that allows for best practices and improved
patient outcomes, when clinically indicated.
RECOMMENDATION 1B: Encourage the use of guidelines that are informed by evidence and created by specialty
organizations and associations that are experts in the treatment of certain pain conditions that result from a variety
of medical conditions or in dierent special populations.
2.1 APPROACHES TO PAIN MANAGEMENT
21PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
2.1.1 Acute and Chronic Pain
Acute pain is a ubiquitous human experience
55
— a physiologic response to noxious stimuli that is sudden in onset and time
limited.
56
Acute pain can occur after a burn or trauma or following surgery in the perioperative period. Acute pain and chronic
pain are often interlinked, with most cases of chronic pain beginning as acute pain.
57
Acute pain flares may recur periodically
in chronic medical problems, including arthritis,
58
neuropathies,
59
spinal conditions, low-back pain,
60
sickle cell disease (SCD),
61
migraine,
62
multiple sclerosis (MS),
63
trigeminal pain or neuralgia,
64
and complex regional pain syndrome (CRPS).
65
As with acute
pain flares in these and other conditions, it is important to perform a thorough evaluation that leads to a presumed diagnosis
or dierential diagnosis. The goal is to facilitate diagnostic accuracy and eective therapeutic plans, including a continuum of
care plans into the non-acute care setting.
66
It is vital to consider a risk-benefit analysis to provide the best possible patient-
centered outcome while mitigating unnecessary opioid exposure (see Section 3.1: Risk Assessment). To avoid the side eects
associated with prescription opioids (e.g., nausea, vomiting, constipation, sedation, OUD), it is important to exploit the benefits
of multimodal, non-opioid approaches in acute pain management in conjunction with possible opioid therapy.
67
Reevaluation of
patients is critical in this setting because the use of medications to control acute pain should be for the shortest time necessary
while also ensuring that the patient is able to mobilize and restore function. Opioids are eective in treating acute pain, but
patients can be at risk of becoming new chronic opioid users in the postsurgical setting. As one large study illustrated, among
a population of opioid-naive patients who were given a course of opioids to treat pain following surgery, about 6% became
new chronic users. Patients who were at higher risk for becoming chronic opioid users were those with a history of tobacco
use, alcohol and substance abuse disorders, anxiety, depression, other pain disorders, and comorbid conditions.
68
This finding
further underscores the value and importance of initial clinician-patient time together as well as appropriate follow-up to better
assess risk and provide appropriate treatment for these complex pain conditions.
• Gabapentinoids
• Tai chi
• Epidural steroid
Injections
• Acupuncture
• Trigger point
injection
• Self-management
• Short-term opioids
• Behavioral health
• Physical therapy
• NSAIDs
• Yoga
• Nerve blocks
Patient D
Patient C
Patient B
Patient A
Therapeutic alliance and
shared decision-making
Diagnostic
Evaluation:
Biopsychosocial
Approach
Pain Management Toolbox*
*This list is non-exhaustive
nor in any particular order
• NSAIDs, OTCs
• Medications
• TENS
• Yoga
• Epidural steroid
injections
• Gabapentinoids
• Interventional
procedures
• Specialty referral
• Massage
• Self-management
• Nerve blocks
• Behavioral health
• Neuromodulation
• Acupuncture
• Neuropathic Rx
• Physical therapy
• Short-term opioid
Clinical
Indication
Integrative
Treatment Plan:
Multimodal,
multidisciplinary,
individualized
Figure 6: Individualized Patient Care Consists of Diagnostic Evaluation That Results
in an Integrative Treatment Plan That Includes All Necessary Treatment Options
2.1 APPROACHES TO PAIN MANAGEMENT
22 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: Multimodal, non-opioid therapies are underutilized in the perioperative, inflammatory, musculoskeletal, and
neuropathic injury settings.
RECOMMENDATION 1A: Use procedure-specific, multimodal regimens and therapies when indicated in the
perioperative period, including various non-opioid medications, ultrasound-guided nerve blocks, analgesia techniques
(e.g., lidocaine, ketamine infusions), and psychological and integrative therapies to mitigate opioid exposure.
RECOMMENDATION 1B: Use multidisciplinary and multimodal approaches for perioperative pain control in selected
patients at higher risk for opioid use disorder (e.g., joint camps, Enhanced Recovery After Surgery [ERAS], Perioperative
Surgical Home [PSH]).
69,70
Key components for optimal pre-habilitation may include preoperative physical therapy
(PT), nutrition, and psychology screening and monitoring; preoperative and postoperative consultation and planning
for managing pain of moderate to severe complexity; preventive analgesia with preemptive analgesic non-opioid
medications; and regional anesthesia techniques, such as continuous catheter-based local anesthetic infusion.
RECOMMENDATION 1C: Encourage Centers for Medicare & Medicaid Services (CMS) and private payers to develop
appropriate reimbursement policies to allow for a multimodal approach to acute pain in the perioperative setting and
the peri-injury setting, including preoperative consultation to determine a multimodal plan for the perioperative setting.
RECOMMENDATION 1D: Use treatment regimens in the peri-injury setting that include various non-opioid and
nonpharmacologic therapies to mitigate opioid exposure, when clinically indicated.
GAP 2: Guidelines for the use of multimodal clinical management of acute pain are needed.
RECOMMENDATION 2A: Encourage public and private stakeholders to develop acute pain management guidelines
for common surgical procedures and trauma management, carefully considering how these guidelines can serve
both to improve clinical outcomes and to avoid unintended negative consequences.
RECOMMENDATION 2B: Emphasize the following in guidelines, which provide an initial pathway to facilitate clinical
decision making:
— Individualized treatment as the primary goal of acute pain management, accounting for patient variability with
regard to factors such as comorbidities, severity of conditions, psychosocial characteristics, surgical variability,
geographic considerations, and community/hospital resources.
— Improved pain control, faster recovery, improved rehabilitation with earlier mobilization, less risk for blood clots
and pulmonary embolus, and mitigation of excess opioid exposure.
To reflect multidisciplinary approaches and the biopsychosocial model of acute and chronic pain management, the following
sections are organized by five major approaches to pain management: medication, restorative therapies, interventional
procedures, behavioral health approaches, and complementary and integrative health.
2.2 MEDICATION
23PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
2.1.2 Perioperative Management of Chronic Pain Patients
Perioperative pain management in patients with chronic pain presents unique challenges,
71,72
particularly for patients with
opioid tolerance or those vulnerable to opioid-associated risks. It can be more challenging to manage patients on long-term
opioid therapy in the perioperative period compared with patients who are opioid naive. Considerations for managing these
patients include the use of multimodal approaches as well as preoperative consultation and planning. In addition, behavioral
interventions show promise for use in the pre- and perioperative periods for the management of postsurgical pain.
73–76
Other
experts have suggested use of perioperative surgical homes for this patient population.
77
Patients with chronic pain whose
pain is managed by a pain management clinician should have this clinician consulted and involved in the planning of their pain
control during and after surgery.
GAPS AND RECOMMENDATIONS
GAP 1: Patients with chronic pain who undergo a surgical procedure often have complex issues that go unaddressed and
may lead to suboptimal care.
RECOMMENDATION 1A: The perioperative team should be consulted to form a treatment plan that addresses the
various aspects that would be necessary for best outcomes in this patient population.
2.2 MEDICATION
Eective pain management, particularly for chronic pain, is best achieved through a patient-centered, multidisciplinary approach
that may include pharmacotherapy.
49,52,78
In general, two broad categories of medications are used for pain management: non-
opioids and opioid classes of medications.
79,80
In response to the public health crisis resulting from the current opioid epidemic, there is a surge of interest in non-opioid
pharmacotherapies for chronic pain.
81–83
Non-opioid medications that are commonly used include acetaminophen, nonsteroidal
anti-inflammatory drugs (NSAIDs), antidepressants (e.g., serotonin-norepinephrine reuptake inhibitors [SNRIs], tricyclic
antidepressants [TCAs]), anticonvulsants, musculoskeletal agents, biologics, topical analgesics and anxiolytics.
83–86
Non-opioid
medications can mitigate and minimize opioid exposure. Each medication has its own risks and benefits as well as mechanism
of action. Dierent medications can complement one another, and their eects can be synergistic when used in combination.
A risk-benefit analysis is always recommended based on the individual patient’s medical, clinical, and biopsychosocial
circumstances (see Section 3.1: Risk Assessment).
Behavioral
Health
Approaches
Interventional
Procedures
Restorative
Therapies
Medications
(Opioid and
Non-opioid)
Complementary
& Integrative
Health
Individualized, Multimodal,
Multidisciplinary Pain Management
Figure 7: Medication Is One of Five Treatment Approaches to
Pain Management
2.2 MEDICATION
24 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
The following paragraphs briefly describe non-opioid medications. This list is not inclusive or exhaustive; rather, it provides
examples of common non-opioid medications. As a general rule, caution should be taken, particularly for over-the-counter
medicine, to ensure that patients are aware of the individual side eects and risks of these medications. Over-the-counter
analgesic medications can be present in or components of common cold and cough medicine; clinicians must ensure that
patients are aware of and discuss all their medications with their doctor or pharmacist.
Acetaminophen can be eective for mild to moderate pain. Risks of acetaminophen include dose-dependent liver toxicity,
especially when the drug is taken at high doses, with alcohol, or by those with liver disease.
87
This risk further illustrates why
patients should be aware of the presence of acetaminophen in both over-the-counter and prescribed combination medications.
NSAIDs such as aspirin, ibuprofen, and naproxen can provide significant pain relief for inflammation, such as from arthritis,
bone fractures or tumors, muscle pains, headache, and acute pain caused by injury or surgery. Nonselective NSAIDs (those
that inhibit the activity of both the cyclooxygenase [COX]-1 and COX-2 enzymes) can be associated with gastritis, gastric ulcers,
and gastrointestinal (GI) bleeding. Conversely, COX-2 inhibitors have fewer GI adverse eects. The use of NSAIDs may be
associated with renal insuciency, hypertension, and cardiac-related events.
Anticonvulsants are medications originally developed to treat seizures, but they are also commonly used to treat dierent
pain syndromes, including postherpetic neuralgia, peripheral neuropathy, and migraine.
88,89
They are often used as part of
a multimodal approach to the treatment of perioperative pain. Some of these agents can eectively treat the neuropathic
components of pain syndromes. Anticonvulsants, which include gabapentinoids such as gabapentin and pregabalin, may cause
significant sedation and have recently been associated with a possible risk of misuse.
90
Antidepressants are commonly used in various chronic pain conditions.
88,91
TCAs are eective in a variety of chronic pain
conditions, including neuropathic pain. As with other medications, they have risks and adverse eects, including dry mouth,
dizziness, sedation, memory impairment, orthostatic hypotension, urinary retention, and cardiac conduction abnormalities.
Trials with dierent TCAs (e.g., desipramine, nortriptyline, amitriptyline) should be initiated at a low dose and gradually titrated
to optimal eect. SNRIs, such as venlafaxine and duloxetine, are eective for a variety of chronic pain conditions, including
musculoskeletal pain, fibromyalgia, and neuropathic pain conditions, but have markedly fewer adverse eects (e.g., lower
risk of drowsiness, memory impairment, and cardiac conduction abnormalities) than TCAs. There have been some reports
of withdrawal reactions when these medications are suddenly stopped.
92
Although selective serotonin reuptake inhibitors
(SSRIs), such as fluoxetine, sertraline, citalopram, and paroxetine, are eective antidepressants; they have less analgesic eect
compared with other antidepressant classes. Overall, the analgesic actions of antidepressants occur even in patients who
are not clinically depressed, and their analgesic eect typically occurs sooner and at lower doses than those required for the
treatment of depression.
This list is not exhaustive
Acetaminophen
AntidepressantsNSAIDs
Anticonvulsants
Anxiolytics Opioids
Musculoskeletal
Agents
Figure 8: Medication Approaches Include Opioid and Non-opioid Options
Common Classes of Pain
Management Medications
2.2 MEDICATION
25PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Musculoskeletal agents commonly used for pain treatment include baclofen, tizanidine, and cyclobenzaprine. Carisoprodol is
metabolized to meprobamate, which is both sedating and possibly addictive, so the use of carisoprodol is not recommended,
particularly because alternatives are available.
93
Antianxiety medications are often prescribed to treat the anxiety that accompanies acute pain as well as anxiety resulting from
fluctuations in chronic pain. They may also be prescribed for co-morbid anxiety disorders such as generalized anxiety disorder,
panic disorder, post-traumatic stress disorder (PTSD), and agoraphobia, which as a group have a prevalence estimated in the range
of 30% in patients with chronic pain.
94,95
SSRIs and SNRIs may also help manage the anxiety associated with co-morbid depression.
It is important to recognize and treat anxiety eectively because it can worsen the severity of pain as well as interfere with a
patient’s coping skills for managing his or her pain. Several classes of medications can be used to treat anxiety. Benzodiazepines
do not have independent analgesic eects but may have indirect pain-relieving eects.
96
Thus, they can be helpful when used
briefly for the anxiety associated with pain in an acute medical setting (e.g., injury, hospitalization), but benzodiazepines should
generally be avoided for regular or long-term use for three reasons. First, benzodiazepines increase the risk of substance use
disorder. Second, co-prescription of benzodiazepines and opioids is associated with enhanced risks of overdose, respiratory
depression, and death.
97–99
Third, the cognitive eects of benzodiazepines, when used chronically, may interfere with a patient’s
development of new coping skills needed to manage a chronic pain condition.
100
For chronic anxiety disorders, usually a
combination of medications indicated for that specific condition plus evidence-based psychotherapy, such as cognitive-behavioral
therapy (CBT) (see Section 2.5: Behavioral Health Approaches), works best.
101,102
SSRIs and SNRIs are the medications most
frequently used for the generalized anxiety that often accompanies chronic pain conditions. Buspirone is another choice. SSRIs,
because of their lower side eect profile, are generally the first choice for panic disorder, but TCAs can also be used. Venlafaxine
ER and prazosin are used for PTSD. For more severe cases of co-morbid anxiety disorders, psychiatric consultation for medication
regimens is advised. (see Section 2.5: Behavioral Health Approaches and Section 4: Review of the CDC Guideline, Gap 6,
Recommendations 6a and 6b). It should be noted that gabapentinoids have been useful in treating anxiety in patients with pain.
103
The following paragraphs briefly describe opioid medications.
Opioids are a controlled substance group of broad-spectrum analgesics that provide pain relief for a variety of conditions.
Administration of opioid medication can include short- or long-acting formulations
104
and dierent delivery modalities, such as oral,
buccal, sublingual, spray, intravenous, intramuscular, intrathecal, suppository, transdermal patches,
105
and lozenge formulation.
Opioids bind to opioid receptors in the brain, spinal cord, and other sites, activating analgesic and reward pathways.
106
It is
important to point out that opioid medications vary in the ratio of their analgesic potency and their potential for respiratory
depression, the major cause of opioid overdose death.
107
For example, synthetic fentanyl and fentanyl analogues (e.g., carfentanil)
are particularly potent for respiratory depression. Illicit fentanyl-related overdoses are now a leading cause of deaths from
overdose in the United States, often because of its use in combination with alcohol or illicitly obtained heroin, cocaine, diverted
prescription opioids, and other drugs such as benzodiazepines. Common prescription opioid medications that can be considered
for management of acute and chronic pain include hydromorphone, hydrocodone, codeine, oxycodone, methadone, and
morphine.
108–111
Although eective for moderate to severe acute pain, the eectiveness of opioids beyond three months requires
more evidence (see Section 4: Review of the CDC Guideline).
112
A recent study demonstrated that treatment with opioids alone
was not superior to treatment with trials of various combinations of non-opioid medications for improving pain-related function
over 12 months; the authors concluded that the results do not support initiation of opioid therapy alone for moderate to severe
chronic back pain or hip or knee osteoarthritis pain.
113
There are challenges to completing long-term studies of any therapy
for moderate to severe pain, particularly patient drop-out from intolerable pain.
114
Opioid medications can be associated with
significant side eects, including constipation, sedation, nausea, vomiting, irritability, pruritis, and respiratory depression.
115–117
Opioid medications can be associated with OUD
118
and can be diverted.
119
Buprenorphine, an opioid medication that the FDA
has approved for clinical use, is a partial agonist at the mu opioid receptor and therefore has a reduced potential for respiratory
depression; it is thus safer than full agonists such as morphine, hydrocodone, and oxycodone.
120,121
Buprenorphine also acts as an
antagonist at the kappa receptor, an eect shown in experimental studies to reduce anxiety, depression, and the unpleasantness
of opioid withdrawal. Buprenorphine is widely used and encouraged for treating patients with OUD and is approved for the
treatment of pain. In some states, there is a significant challenge, however, for prescribing clinicians to get authorization for using
buprenorphine for chronic pain management (see Section 2.2: Medication, Gap 4 and Recommendations).
2.2 MEDICATION
26 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Tapentadol is structurally similar to tramadol, and both have a dual mode of action as an agonist at the mu opioid receptor and as
a serotonin and norepinephrine reuptake inhibitor. Tapentadol is at least equivalent to oxycodone in terms of analgesia, with better
GI tolerability.
122
As outlined in recent guidelines, including the VA/DoD Clinical Practice Guidelines for Opioid Therapy for Chronic Pain, the
CDC Guideline, and the American Society of Interventional Pain Physicians guidelines, risk assessment, close follow-up, and
pain reevaluation are important aspects of the treatment plan prior to and throughout the duration of opioid therapy for pain
management.
32,123,124
Initiation of opioid therapy, when the patient and the clinician deem the benefits to outweigh the risks, should
be at a low dose and titrated upward to find the lowest dose required to optimally control the pain or improve function and QOL.
Opioid treatment should be maintained for a period no longer than necessary for adequate pain control.
32,49,123
Similarly, assessing
for tolerance and consideration of adjunctive therapies, opioid rotation, tapering, and discontinuation should be considered.
32,123,125
Safe opioid stewardship involves a proper history and examination, periodic reevaluation, and risk assessment, with a focus on
measurable outcomes, including function, QOL and ADLs.
32,49,123
Accurate dose adjustment is critical because patients vary widely
in the dose required for analgesic ecacy.
126,127
The idea of a ceiling dose of opioids has been recommended, but establishing such a ceiling is dicult, and the precise level
for such a ceiling has not been established.
128
The risk of overdose increases with the dose, but the therapeutic window varies
considerably from patient to patient. For example, the CDC Guideline identified a dose limit of 90 morphine milligram equivalents
(MMEs) per day. A more recent study evaluated the risk of death related to opioid dose in 2.2 million North Carolinians and found
that the overall death rate was 0.022% per year.
129
The researchers noted that:
“Dose-dependent opioid overdose risk among patients increased gradually and did not show evidence of a distinct
risk threshold. Much of the risk at higher doses appears to be associated with co-prescribed benzodiazepines. It is
critical to account for overlapping prescriptions, and justifies taking a person-time approach to MME calculation with
intent-to-treat principles.”
DEA has classified medications according to categories, or “schedules,” based on the perceived risk of addiction. These scheduled
medications require prescribers to register with DEA. Opioids are mainly category CIII (relatively lower risk) or CII (higher risk).
CIII medications include acetaminophen with codeine and buprenorphine, while CII medications include hydrocodone (recently
changed from a CIII to a CII classification), oxycodone, morphine, fentanyl, and methadone. CIV drugs are defined as drugs with
a low potential for abuse and low risk of dependence, such as Tramadol. CI medications are those that are considered not to
have medicinal value, including heroin, methamphetamine, and cannabis. (Although marijuana/cannabis is legal for medical use in
several states, it is illegal at the federal level.)
I am a soon to be 50-year-old man that has sickle-cell anemia. And it runs in my family. I
come from a family of 12 siblings. And out of the 12, fi ve of us have sickle-cell anemia. I’m not
an advocate by any way for opioids. But they are a part of our tool box that helps us maintain
a quality of life. We get labeled as drug seekers. They don’t think of us as fathers, husbands,
sons, grandfathers. They just look at us as another number or as those patients coming in
seeking drugs. In my life, opioids help me have a quality of life. I know how now not to get
stressed out. I have all sorts of other things that I try before just taking medication. OxyContin
is one of the medications that I take. And, yes, you have to take it every 12 hours daily. So,
yes, that’s part of my regimen. But I also do other things-- vitamins, try to eat healthy, try not to
be stressed out-- just all sorts of things to help myself. I am a grandfather. I have two children.
I have three grandkids. Please look at each case individually because everybody can’t be
lumped into one barrel together. I’ve been taking this medication since ‘95 and I take a really
high amount. But I only take enough to be able to function. I’m not trying to get loopy and be
out of my mind. That was never my intention. I take it because of the pain. But the main thing
is, we need opioid medications to be an option in the tool box.
JONATHAN’S
STORY
PATIENT TESTIMONIAL
2.2 MEDICATION
27PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Opioids: Additional Considerations
The following paragraphs briefly describe additional considerations relevant to medications used for pain management.
Medicines play an important role in treating certain conditions and diseases, but they must be taken with care and stored
securely where they cannot be misused by a third party or accidentally ingested by children or pets.
130
Unused portions of
these medicines must be disposed of properly to avoid harm. Patients and caregivers can remove expired, unwanted, or
unused medicine from their home as soon as they are no longer needed to help reduce the chance that others accidentally
or intentionally misuse the unneeded medicine and to help reduce drugs from entering the environment. There are various
take-back options such as DEA National Takeback Days, pharmacy takeback (in some locations), drop boxes in many local
law enforcement oces, drug deactivation systems, and mail-back options. The FDA maintains a list of medicines that
are potentially dangerous if diverted and should be flushed in the toilet (see Federal Resource Center).
130
Practicing safe
medication storage is important; patients, caretakers, providers, and pharmacists should be educated in the various ways to
keep them safe at home (https://www.cdc.gov/features/medicationstorage/index.html).
131
Synthetic opioids other than methadone (a category that includes prescribed and illicit fentanyl and fentanyl analogues) are
now the leading opioids involved in overdose deaths in the United States.
108–110
The source of illicit fentanyl and its analogues
has been identified as international and rarely from diverted fentanyl pharmaceuticals in the United States. These sources
currently come through the U.S. Postal Service, borders, ports of entry, and other means. The illicit fentanyl analogues used
are not necessarily the same product that is legally prescribed and used during surgeries or in the transdermal and mucosal
fentanyl preparations provided for moderate to severe pain. One illicit analogue that has been seen is called carfentanil, which
is 100 times more potent than fentanyl. The availability of naloxone as well as patient and family education about naloxone can
mitigate the risks of fentanyl-related overdose.
132
Prescribers may oer a naloxone prescription to patients who are prescribed opioids (co-prescription) or to those with an
addiction history who may be at risk for relapse. In many states, people may obtain naloxone without seeing their provider
by obtaining a prescription through standing-order programs with pharmacies. Timely administered naloxone can reverse
overdose from opioids whether the opioid is prescribed or illicitly obtained (see Section 2.2.1: Overdose Prevention Education
and Naloxone).
Interaction among multiple medications prescribed to patients (polypharmacy) can have significant clinical and symptomatic
eects. Poison control centers are available 24/7 to health care professionals and the public to answer questions about
medication interactions and adverse eects and to assess the need for emergency health care resources.
133,134
Poison control
center engagement is associated with significant reductions in unnecessary use of emergency medical services, EDs, and
hospital resources, resulting in significant cost savings for the U.S. health care system.
135,136
Increased provider and patient
awareness and education on the complex and variable interactions of prescribed medications as well as homeopathic,
supplemental, and/or over-the-counter medications is needed.
137
Abuse-deterrent technologies are being developed with the goal of preventing alterations of prescription opioid formulations
and the extraction of the active ingredients by users.
138,
For example, some abuse-deterrent formulations (ADFs) have a
hardened tablet surface that prevents crushing, while others turn into a gooey substance upon crushing; both formulations are
designed to limit the potential for injecting the core substance.
140
ADFs also include the addition of pharmaceutical or chemical
compound to the opioid to decrease the user’s response to the abused substance or to provide an adverse reaction when the
medication is altered.
139
To address misuse of prescription opioids, the FDA released guidance in 2015 for the development of
opioids formulated to meaningfully deter abuse.
138
A challenge to the development of opioid ADFs is the need to maintain the
same safety and ecacy profile as the opioid without the ADF for FDA approval.
139,141,142
ADFs are not widely used, and more
research is needed for better product development to reduce opioid misuse. (The review of ADFs is mentioned specifically for
review in the CARA legislation.)
2.2 MEDICATION
28 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: Clinical policies tend to treat the large population of patients with multiple conditions that cause chronic pain with simple
medication rules. Guidelines for medication use for specific populations of patients (e.g., dierent ages, genders, medical
conditions, comorbidities) with chronic pain need to be developed for each specialty group and setting.
RECOMMENDATION 1A: Develop condition-specific treatment guidelines that guide physicians to have a more
individualized approach to common pain syndromes and conditions. A multidisciplinary approach that integrates the
biopsychosocial model is recommended when clinically indicated.
RECOMMENDATION 1B: Primary care and non-pain specialists should have timely, early consultation with pain
specialists and other members of the pain management team for the assessment of patients with complex pain to
prevent complications and loss of function and to improve QOL, as clinically indicated.
RECOMMENDATION 1C: Develop a collaborative, multimodal treatment plan as clinically indicated among the
referring physician, the pain medicine team, and the patient.
RECOMMENDATION 1D: Pharmacies should collaborate with area health care providers to develop more eective
and patient-friendly delivery systems to meet the needs of their patients.
GAP 2: Opioids are often used early in pain treatment. There has been minimal pain education in medical school and residency
programs, and little guidance for PCPs on appropriate pain treatment approaches (see Section 3.3.3: Provider Education;
see Section 3.4: Access to Pain Care).
RECOMMENDATION 2A: Non-opioids should be used as first-line therapy whenever clinically appropriate in the
inpatient and outpatient settings.
RECOMMENDATION 2B: If an opioid is being considered, clinicians should use evidence-informed guidelines.
RECOMMENDATION 2C: The type, dose, and duration of opioid therapy should be determined by treating clinicians
according to the individual patient’s pain condition while using the opioid medication at the lowest eective dosage
and shortest duration appropriate to achieve adequate pain control for improved function and QOL.
RECOMMENDATION 2D: Opioid therapy should be initiated only when the benefits outweigh the risks; the
patient is experiencing significant acute or chronic pain that interferes with function and QOL; and the patient
is willing to continue to engage with the team on a comprehensive multidisciplinary treatment plan, as clinically
indicated, with established clear and measurable treatment goals, along with close follow-up and regular risk
assessment and reevaluation.
RECOMMENDATION 2E: CMS and private payers should provide reimbursement that aligns with the medication
guidelines the Task Force has described. Private payers and CMS should provide more flexibility in designing
reimbursement models.
RECOMMENDATION 2F: Pharmacy Benefit Managers (PBM) and payers should be more transparent about non-
opioid pharmacologic options in their formulary, and the Task Force encourages state and federal regulators to
review payer and PBM formularies to ensure that non-opioid options are on low-cost tiers.
GAP 3: There is often a lack of understanding and education regarding the clinical indication and eective use of non-opioid
medications for acute and chronic pain management. Chronic pain is often ineectively managed for a variety of
reasons, including clinician training, patient access, and other barriers to care (see Section 3.3: Education):
RECOMMENDATION 3A: Clinicians who treat chronic pain should understand the full complement of options,
including the use of non-opioid medications and their mechanism-based pharmacology for managing dierent
components of pain syndromes. (See Section 2.3: Restorative Therapies, Section 2.4: Interventional Procedures;
Section 2.5: Behavioral Health Approaches; and Section 2.6: Complementary and Integrative Health.)
2.2 MEDICATION
29PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
RECOMMENDATION 3B: For neuropathic pain, as a first-line therapy, consider anticonvulsants (e.g., gabapentin,
pregabalin, carbamazepine, oxcarbazepine), SNRIs (e.g., duloxetine, venlafaxine), TCAs (e.g., nortriptyline, amitriptyline),
and topical analgesics (e.g., lidocaine, capsaicin). Regardless of the route of medication, education regarding the side
eects as well as risks and benefits is vital in terms of understanding clinical indications and patient outcomes.
RECOMMENDATION 3C: For non-neuropathic, noncancer pain, use NSAIDs and acetaminophen as first-line classes
of medications, following standard dosing schedules when clinically appropriate. Other classes of medication can be
used depending on the patient’s response and may include (depending on specific pain syndromes) antispasticity
medications (e.g., tizanidine, baclofen) and topical preparations of various classes of medication in addition to other
multimodal approaches. Additional consideration may be given to SNRIs or TCAs.
GAP 4: Barriers include lack of coverage and reimbursement for buprenorphine as well as the lack of education and training on
the proper usage of buprenorphine. There has been a lack of access to buprenorphine treatment for chronic pain.
143
RECOMMENDATION 4A: Make buprenorphine treatment for chronic pain available for specific groups of patients,
and include buprenorphine in third-party payer and hospital formularies.
RECOMMENDATION 4B: Encourage CMS and private payers to provide coverage and reimbursement for
buprenorphine treatment, both for OUD and for chronic pain. Encourage primary use of buprenorphine rather than
use only after failure of standard mu agonist opioids such as hydrocodone or fentanyl, if clinically indicated.
RECOMMENDATION 4C: Encourage clinical trials using buprenorphine for chronic pain to better understand
indication, usage, and dosage.
GAP 5: Education is currently inadequate for patients and clinicians regarding safe medication storage and appropriate disposal
of excess medications targeted at reducing outstanding supplies of opioids that others can misuse or that children and
other vulnerable members of the household can inadvertently access.
RECOMMENDATION 5A: Increase public awareness of poison control center services as a resource that provides
educational outreach programs and materials; referral to treatment facilities; links to take-back facilities; and
resources for safe drug storage, labeling, and disposal.
RECOMMENDATION 5B: HHS, in partnership with DEA and other federal and state agencies, should increase
opportunities for safe drug disposal and drug disposal sites (e.g., pharmacies, police departments).
RECOMMENDATION 5C: Adopt neutralization technologies and methods that may make safe disposal more readily
available for opioids and other relevant medications.
RECOMMENDATION 5D: Educate all providers, including veterinarians, on the importance of safe storage and
disposal of opioid medications in their practice. In addition, educate patients and pet owners about the importance
of safe storage and disposal of opioid pain medication prescribed for their pets.
2.2 MEDICATION
30 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
2.2.1 Overdose Prevention Education and Naloxone
Naloxone is a medication designed to rapidly reverse opioid overdose.
144,145
It is an opioid antagonist that binds to opioid
receptors and can reverse and block the eects of other opioids. It can quickly restore normal respiration to a person whose
breathing has slowed or stopped as a result of overdosing with illicit fentanyl, heroin, or prescription opioid pain medications.
The use of naloxone to treat those who have overdosed on opioids by family members, bystanders, and first responders can
save lives,
146
and both intramuscular and nasal formulations are available. Widespread, rapid availability of bystander and take-
home naloxone rescue kits, coupled with enhanced education on naloxone’s proper use, is essential, particularly in cases where
higher doses of opioids are to be prescribed or there is evidence of underlying OUD, as emphasized by the Surgeon General of
the U.S. Public Health Service, Vice Adm. Jerome Adams’, advisory on naloxone and opioid overdose.
147,148
COST EFFECTIVE
Total healthcare cost
savings: >$1.8 Billion
Reduce ED visits, hospital
admissions, and hospital
length of stay in addition
to injury prevention
SPECIAL POPULATIONS
Geriatric, pediatric, and other
special patient populations
SUBSTANCE
USE DISORDER
Manage intoxication,
withdrawal, & medication
assisted treatment (MAT)
ACCESSIBLE
Nationwide and
FREE to the public,
24/7/365
EDUCATION
Prevention and stigma
reducing programming for
all audiences
MEDICATIONS
Provide medication
safety, adverse eect,
and medical
treatment advice
OVERDOSE
Assist with naloxone
access, training, and
administration;
treatment of overdose
and attempted suicide
DATA
Near real-time national
surveillance & reporting
Figure 9: Value of Poison Control Centers
2.3 RESTORATIVE THERAPIES
31PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: Bystander/take-home naloxone distribution is associated with a cost-eective reduction in mortality; however, its
optimal use is not widely understood, and it is not widely distributed.
RECOMMENDATION 1A: Provide naloxone co-prescription/dispensing and education for certain patients and family
members/caregivers when the patient is on chronic opioid therapy.
RECOMMENDATION 1B: Increase naloxone distribution programs and education for first responders.
RECOMMENDATION 1C: Encourage the FDA and other entities to research the potential risks and benefits of
making naloxone available over the counter.
RECOMMENDATION 1D: Educate health care providers and the public on the importance of identifying individuals at
higher risk of overdose harm because of their history or findings consistent with substance abuse, co-prescription or
illicit use of drugs or substances that cause sedation or respiratory depression, or evidence of respiratory compromise.
2.3 RESTORATIVE THERAPIES
Restorative therapies include treatments provided by PT and occupational therapy (OT) professionals, physiotherapy,
therapeutic exercise, and other movement modalities that are provided as a component of interdisciplinary, multimodal pain
care. Restorative therapies play a significant role in acute and chronic pain management, and positive clinical outcomes
are more likely if restorative therapy is part of a multidisciplinary treatment plan following a comprehensive assessment.
Restorative therapies can be administered by physical therapists, occupational therapists, and others in a variety of settings.
Patient outcomes related to restorative and physical therapies tend to emphasize improvement in outcomes, but there is
value in restorative therapies to help maintain functionality. Use of restorative therapies is often challenged by incomplete or
inconsistent reimbursement policies. The Task Force asks health care reimbursement policymakers to closely evaluate and
advocate for payers to improve access to a range of restorative therapies.
The following paragraphs briefly describe restorative therapies, which can be considered singularly or combined with other
therapies as part of a multimodal approach to the management of chronic and acute pain, depending on the patient and his or
her medical conditions. This list is not inclusive or exhaustive but instead provides examples of common restorative therapies.
Therapeutic exercise and its role in the treatment of pain is tied to the underlying diagnosis for the pain. Bed rest was
scientifically recognized and prescribed as a treatment for low-back pain as recently as the 1980s,
149
but high-quality scientific
evidence has since emerged establishing the superiority of movement therapies over rest.
150
The majority of pain-related
PT guidelines exist for the treatment of spinal pain. In addition to improving physical functioning, a more contemporary
Behavioral
Health
Approaches
Interventional
Procedures
Restorative
Therapies
Medications
(Opioid and
Non-opioid)
Complementary
& Integrative
Health
Individualized, Multimodal,
Multidisciplinary Pain Management
Figure 10: Restorative Therapies Are One of Five Treatment
Approaches to Pain Management
2.3 RESTORATIVE THERAPIES
32 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
biopsychosocial treatment approach to therapeutic exercise helps patients understand and overcome “secondary
pathologies,” including fear of movement and anxiety that contribute to pain and disability.”
51
Transcutaneous electric nerve stimulation (TENS) has been applied to treat pain, but studies of its ecacy are lacking in
number and design, with high risks of bias commonly reported.
151
An evaluation of 49 systematic reviews, randomized controlled
trials (RCTs), and observational studies found insucient evidence to assess the eectiveness of TENS for acute low-back
pain.
152
More recent individual studies have investigated the eectiveness of TENS for postpartum pain,
153
phantom limb pain,
154
and knee osteoarthritis.
155
Despite the overall limited evidence of ecacy, partially stemming from a lack of large RCTs, TENS is
considered a safe self-care option for patients (with appropriate education).
156
Massage therapy can be eective in reducing pain.
157
There are a variety of types of massage therapy, including Swedish,
shiatsu, and deep tissue (myofascial release).
158,159
In Swedish massage, the therapist uses long strokes, kneading, and deep
circular movements. Shiatsu massage uses the fingers, thumbs, and palm to apply pressure. Deep tissue massage focuses on
myofascial trigger points, with attention on the deeper layers of tissues.
Traction is a PT technique used to treat spinal pain. Review of the evidence has failed to demonstrate the clinical eectiveness
of traction as an eective, evidence-based best practice; however, the field in general lacks high-quality RCTs that examine
eectiveness of traction as an isolated treatment modality for low-back
152,160
or neck pain.
Cold and heat have been used in the treatment of symptoms of a variety of acute and chronic pain conditions. The application
of cold has long been a component of the RICE (rest, ice, compression, elevation) paradigm for the treatment of acute pain
syndromes. Because it treats only symptoms, the eects and duration of this therapy are mitigated by the initial cause of the pain.
For instance, cold therapy has been shown to decrease the pain of hip arthroplasty on the second but not the first or third day
after surgery and did not decrease blood loss from the surgery.
162
Evidence is not robust for all locations and types of pain, but
significant evidence exists for the ecacy and safety of heat wraps in specific conditions, most notably for acute low-back pain.
In fact, a review of non-pharmacologic therapies found that superficial heat had good evidence of ecacy for treatment of acute
low-back pain.
163
Another review found moderate evidence for heat wraps for both symptom and functional improvements.
152
Therapeutic ultrasound (TU) is thought to deliver heat to deep tissues for improved injury healing.
164,165
A 2001 review
concluded that there was little evidence that TU is more eective than placebo for pain treatment in a range of musculoskeletal
conditions.
166
More recent reviews of specific pain syndromes available through the Cochrane Database of Systematic Reviews
reveal similar findings, although there is some evidence for TU in knee osteoarthritis.
167,168
Bracing has sometimes been discouraged in pain management because of fears of deconditioning and muscle atrophy.
However, there is evidence that, for at least short periods of time, bracing (especially nonrigid bracing) may improve function
and does not result in muscle dysfunction.
169
Bracing should be part of the clinician tool box.
GAPS AND RECOMMENDATIONS
GAP 1: There is a lack of clarity on which restorative therapy or treatments are indicated in the various pain syndromes.
RECOMMENDATION 1A: Conduct further research to provide data on which restorative therapy or treatments are
indicated as part of a multidisciplinary approach to specific pain syndromes.
RECOMMENDATION 1B: For those modalities for which clear indications of benefits in the treatment of chronic pain
syndromes (e.g., treatments used by OT and PT professionals; aqua therapy; TENS; movement-based modalities,
including tai chi, Pilates, and yoga), there should be minimal barriers to accessing these modalities as part of a
recommended multidisciplinary approach to the specific pain condition.
RECOMMENDATION 1C: Make harm-free, self-administered therapies such as TENS freely available (e.g., over the
counter) to support pain management treatment plans.
2.4 INTERVENTIONAL PROCEDURES
33PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
2.4 INTERVENTIONAL PROCEDURES
Interventional pain management, or interventional pain medicine, is a medical subspecialty of pain medicine that diagnoses
and treats pain with minimally invasive interventions that can alleviate pain and minimize the use of oral medications. Most
interventional pain physicians oer interventional therapies for acute and chronic pain conditions as part of a comprehensive
treatment program.
170
Many interventional pain procedures have been around for decades, and they vary in their invasiveness.
Image-guided interventional procedures (using ultrasound, fluoroscopy, and computed tomography) can greatly benefit
comprehensive assessment and treatment plans by identifying the sources and generators of pain.
171
Diagnostic and therapeutic
interventional techniques can be valuable options prior to the initiation of extensive surgery, initiation of opioid treatment,
or in concert with other treatment modalities. Additional research and more specific data establishing the clinical benefits of
specific interventional procedures for specific pain conditions would be beneficial and can further identify various procedures
for specific clinical conditions,
172
particularly for certain populations, such as children.
173
Many interventional pain procedures are
available on an outpatient basis, which is vital to ensuring cost-eective access to care. Some minor interventional procedures
can be performed in the primary care setting, while other more advanced procedures require specialty training. The measure
of a successful outcome depends on whether the intervention is used to treat short-term, acute flares or is part of a long-term
management plan that will depend on the individual patient and his or her unique medical status.
Behavioral
Health
Approaches
Interventional
Procedures
Restorative
Therapies
Medications
(Opioid and
Non-opioid)
Complementary
& Integrative
Health
Individualized, Multimodal,
Multidisciplinary Pain Management
Figure 11: Interventional Procedures Are One of Five Treatment
Approaches to Pain Management
2.4 INTERVENTIONAL PROCEDURES
34 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Example Interventional Procedures
Degree of Complexity
• Trigger Point Injections
• Joint Injections
• Peripheral Nerve Injection
• Facet Joint Nerve Block
• Epidural Steroid Injections
• Radio-Frequency Ablation
• Regenerative/Adult Autologous Stem Cell Therapy
• Celiac Plexus Blocks
• Cryoneuroablation
• Neuromodulation
• Spinal Cord Stimulator
• Intrathecal Pain Pumps
• Epidural Adhesiolysis
• Vertebral Augmentation
• Interspinous Process Spacer Devices
• Percutaneous Discectomy
This list is not exhaustive
Figure 12: Interventional Procedures Vary by Degree of Complexity and Invasiveness
The following paragraphs briefly describe interventional procedures that can be considered singularly or as part of a multimodal
approach to the management of chronic and acute pain, depending on the patient and his or her medical conditions. This list is
not inclusive or exhaustive but instead provides examples of common interventional procedures.
Epidural steroid injections (ESIs) deliver anti-inflammatory medication directly into the epidural space — the region outside the
sac of fluid surrounding the spinal cord. Lumbar epidural injections treat back pain and radicular pain resulting from chemical
irritation of nervous tissue by eliminating the inflammatory compounds mediating nervous tissue irritation in the epidural space.
174
ESIs are one of the most common procedures in pain management and, in well-selected patients, can provide significant
pain relief as part of a pain management plan.
175
Although risks are associated with ESIs, they oer significant advantages to
the patient — notably, they may potentially reduce health care costs, health care utilization, and the need for future surgical
intervention.
176
Transforaminal ESIs and selective nerve root injections are specialized approaches to the epidural space that
target specific nerve root pathology.
Facet joint nerve block and denervation injection are common fluoroscopy-guided procedures for facet-related spinal pain
of the low back and neck area in which local anesthesia with or without steroids is injected onto the medial branch nerves that
supply these joints (medial branch blocks or less commonly directly into the facet joint). These injections are primarily diagnostic
but can also be therapeutic, providing long-term relief. If there is only temporary relief, these nerves can be ablated by using
radio-frequency (RF) ablation
177,178
or cryoneuroablation.
179
Facet pathology is a common cause of low-back pain as well as cervical
pain caused by facet joint sprain (cervical whiplash) or degenerative changes and have proven eective in the treatment and
diagnosis of cervical pain, axial back pain, and chronic spinal pain originating from facet joints.
177,180–182
Compared with some
intraspinal interventional treatments, procedures related to the facet joints can be simpler and carry lower risk.
180
Sacroiliac pathology is a type of spinal pain that can mimic herniated disc pain.
183
These joints are not well imaged on standard
magnetic resonance imaging views, and diagnosis is made by precise injections of local anesthesia and corticosteroids into the
joint using fluoroscopy, ultrasound, or computed tomography, while long-term relief can often be obtained by denervating the
nerves going to these joints.
184
Cryoneuroablation (also known as cryoneurolysis and cryoanalgesia) is a specialized interventional pain management technique
that uses a cryoprobe to freeze sensory nerves at the source of pain and provide long-term pain relief.
185,186
Cryoneuroablation is
indicated for numerous persistent and intractable painful conditions, including paroxysmal trigeminal neuralgia, chest wall pain,
187
phantom limb pain,
188
neuroma, peripheral neuropathy,
187
knee osteoarthritis,
189
and neuropathic pain caused by herpes zoster.
185,190
2.4 INTERVENTIONAL PROCEDURES
35PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Radiofrequency ablation. Conventional RF lesioning and pulse RF (PRF) are both ways to ablate certain nerves that have
been identified as contributing to chronic pain syndromes, and they continue to have great value as a treatment modality in
the management of a variety of pain syndromes. Furthermore, studies have shown that conventional RF provides benefits in
appropriate patients.
186,191
PRF uses short, high-voltage bursts of energy produced by needles inserted next to nerves to “stun”
them, thereby blocking transmission of pain signals.
192,193
Although more research is required to better understand both the
exact mechanism of action of PRF and its ecacy in treating various chronic pain syndromes, PRF has already demonstrated its
potential as a promising interventional modality in the treatment of cervical radicular pain,
194
though there is no Current Procedural
Terminology (CPT) code for the technique, and insurance typically does not cover it.
Peripheral nerve injections, commonly referred to as peripheral nerve blocks (PNBs), are injections of local anesthetic agents
frequently mixed with anti-inflammatory steroid medication or clonidine for both diagnostic and therapeutic pain relief purposes.
195
Administered either through a single injection or in a continuous infusion by catheter, PNBs are often employed in the perioperative
and postoperative period for acute pain care.
196,197
PNBs are advantageous in that they allow for quicker discharge times in
ambulatory settings, less postoperative nausea and vomiting because less opioid medication is used, and improved patient
satisfaction. There has been a growth in this area as part of improved perioperative pathways and the use and advancements in
ultrasound-guided nerve blocks that allow for more eective anesthetic blocks.
198,199
Ultrasound has also improved the ability to
diagnose and treat peripheral neuropathies and nerve entrapments,
200,201
and PNBs can also have a role in potentially diminishing
or preventing the development of chronic pain syndromes
202,203
such as CRPS,
204
headaches,
205
pelvic pain,
206
and sciatica.
207
Sympathetic nerve blocks (SNBs), similar to PNBs, are injections of local anesthesia at the sympathetic nerve chain that can be
used to diagnose or treat pain that involves the sympathetic nervous system.
208
SNBs have been used to treat neuropathic pain,
Complex Regional Pain Syndrome” 1 (reflex sympathetic dystrophy), and CRPS 2 (causalgia) as well as manage chronic abdominal,
pelvic, and perineal pain.
209–211
Neuromodulation techniques use device-based electrical or magnetic stimulation to activate central or peripheral nervous
system tissue associated with pain pathways to produce analgesia or reduce sensitivity to pain. This is an area of growth and
innovation for chronic pain treatment, including neuropathic pain, and for both the central and peripheral nervous systems.
212,213
Spinal cord stimulation using a variety of waveforms and frequencies and dorsal root ganglion stimulation, collectively, have
five level-1 studies demonstrating their ecacy in low-back and lower extremity pain.
214–218
Peripheral nerve stimulation has
gained popularity and eectiveness with the recognition of peripheral nerve entrapments, increased use of ultrasound, and
improvement in technology. More recently, noninvasive neuromodulation therapies have been studied in headache disorders.
Multiple level-1 and level-2 studies have demonstrated that noninvasive vagus nerve stimulation can be eective in ameliorating
pain in various types of cluster headaches and migraines.
219–221
These therapies provide an electric field to the brain, cranial
nerves, or peripheral nerves without actually requiring a surgical procedure or implant.
Intrathecal Medication Pumps. Because there are opioid receptors on the spinal cord and at specific areas of the brain,
significantly smaller doses of opioids in the spinal fluid can provide significant analgesia at much lower doses than oral opioids.
Implanted intrathecal pumps with catheters in the spinal fluid can supply medication continuously, and they have been used
for both cancer and noncancer pain.
222
The largest trial ever performed in cancer patients demonstrated improved pain control
with fewer side eects and a trend toward improved life expectancy with implantable pumps.
223
However, there are significant
side eects, including delayed respiratory depression, granuloma formation, and opioid-induced hypogonadism.
224
Other
medications, such as ziconotide (a calcium channel blocker made from cone snail venom), baclofen (to treat spasticity), and
clonidine (an alpha agonist agent) can also be used in these pumps.
Vertebral augmentation stabilizes the spine through the application of cement to vertebral compression fractures that are
painful and refractory to medical treatment;
225
this approach can include vertebroplasty (injecting cement into a fractured
vertebra) or balloon kyphoplasty (using an inflatable balloon to create injection space). Evidence suggests that balloon-assisted
kyphoplasty is one of the most eective vertebral augmentation procedures.
226,227
Vertebral augmentation has also been
combined with RF ablation to manage pain resulting from vertebral damage secondary to fractures from various conditions or as
a result of spinal metastases.
228
Trigger points are palpable, tense bands of skeletal muscle fibers that, upon compression, are capable of producing both local
and referred pain.
229
Using either dry needling or injections of local anesthesia, trigger points can be disrupted, resulting in
relaxation and lengthening of the muscle fiber, thereby providing pain relief.
229,230
Trigger point injections can be used to treat
2.4 INTERVENTIONAL PROCEDURES
36 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: Interventional pain procedures can provide diagnostic information when evaluating patients in pain and provide pain relief.
A comprehensive assessment by a skilled pain specialist is necessary to identify which procedure is indicated for a given
patient’s pain syndrome. Unfortunately, pain specialists are typically not involved in the multidisciplinary approaches of
diagnosing and treating a pain patient early enough in his or her treatment, which can lead to suboptimal patient outcomes.
RECOMMENDATION 1A: Adopt well-researched interventional pain guidelines to guide the appropriate use of
interventional pain procedures as a component of a multidisciplinary approach to the pain patient. Guidelines are
particularly important for guiding the collaboration of PCPs and pain medicine specialists.
RECOMMENDATION 1B: Conduct additional clinical research that establishes how interventions work in conjunction
with other approaches in the process of caring for patients with chronic pain, especially early in the process, when
combined appropriately with goal-directed rehabilitation and appropriate medications.
pain associated with headaches, myofascial pain syndrome, and low-back pain.
231–233
Other types of direct injections include
intramuscular, intrabursal, and intra-articular injections for muscle pain, bursitis, and joint pain, respectively.
Joint Injections. In addition to the facet joints, corticosteroid injections into other joints (e.g., shoulder, elbow, wrist, knee, ankle)
are common interventional procedures, particularly in the treatment of inflammatory arthritis and basal joint arthritis.
234,235
When
local anesthesia is combined with corticosteroids, the joint injection can also be used therapeutically to treat joint pain resulting
from injury or disease or diagnostically to identify the source of joint pain.
236
Interspinous Process Spacer Devices. Research has shown that interspinous process spacer devices can provide relief for
patients with lumbar spinal stenosis with neuroclaudication.
237,238
Regenerative/adult autologous stem cell therapy may show promise in the treatment of multiple painful conditions.
–241
Further
research is needed and encouraged to investigate the potential of these therapies.
The risk of interventional therapies varies by procedure. Interventional treatments have some associated risk (e.g., small risk of
infection or nerve injury), but the overall safety and ecacy of interventional therapies make them attractive alternatives to long-
term opioid therapy when performed by properly trained and certified clinicians.
I was diagnosed with ulcerative colitis and eventually complex pain. Additionally, I had an
allergy to a medication that made things worse. I had surgical removal of my colon and it was
replaced with a J-pouch. Two years later, I had surgery again, which resulted in severe pain.
At that time, we left Canada and moved to the USA.
Ultimately, I [was] referred to the pain management clinic at my hospital. I was o ered trigger-
point injections and they turned out to be a breakthrough. The physical therapy helped me a
lot and was coordinated with the trigger point injection. I regained my life. It was an extremely
bad and very challenging situation. I don’t have as much uncontrolled pain as I used to.
My doctor helped me, by pinpointing the exact area of the pain and the neuroma, the pinched
nerve. I also have severe pain from migraines. Botox injections on my neck and forehead
were a huge breakthrough too. Every four months I’m totally pain free. As it gets closer and
closer to that four months, I need another injection.
Reiki, or touch healing, also helped me. It doesn’t cure anyone, but it gives you power to
face problems and calm you. I also, very rarely, take a pain opioid pill, Tylenol Number 3, for
severe acute fl ares of my pain. However, not everybody who takes that kind of pill should be
considered addicts.
FARSHAAD’S
STORY
PATIENT TESTIMONIAL
2.5 BEHAVIORAL HEALTH APPROACHES
37PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
RECOMMENDATION 1C: Establish criteria-based guidelines for properly credentialing clinicians who are appropriately
trained in using interventional techniques to help diagnose, treat, and manage patients with chronic pain.
GAP 2: Inconsistencies and frequent delays exist in insurance coverage for interventional pain techniques that are clinically
appropriate for a particular condition and context.
RECOMMENDATION 2A: Encourage CMS and private payers to provide consistent and timely insurance coverage
for evidence-informed interventional procedures early in the course of treatment when clinically appropriate. These
procedures can be paired with medication and other therapies to improve function and QOL.
RECOMMENDATION 2B: CMS and other payers must restore reimbursement to nonhospital sites of service to
improve access and lower the cost of interventional procedures.
GAP 3: There is a trend of inadequately trained clinicians performing interventional procedures. This trend can potentially lead to
serious complications and inappropriate utilization.
RECOMMENDATION 3A: Establish credentialing criteria for minimum requirements for training clinicians in
interventional pain management.
RECOMMENDATION 3B: Only clinicians who are credentialed in interventional pain procedures should perform
interventional procedures.
2.5 BEHAVIORAL HEALTH APPROACHES
In recent decades, pain management experts have recognized the important relationship between pain and psychological
health.
40,242,243
Psychological factors can play an important role in an individual’s experience and response to pain
244,245
and can
aect treatment adherence, pain chronicity, and disability status.
242,246
Undiagnosed and untreated psychological concerns in
individuals with pain are associated with increased health care utilization and readmissions, decreased treatment adherence,
and increased disability.
247–249
Patients with chronic pain are at increased risk for psychological distress, maladaptive coping, and
physical inactivity related to fear of reinjury.
40
Individuals with chronic pain are also more likely to have disabilities than patients
with other chronic health conditions, such as stroke, kidney failure, cancer, diabetes, or heart disease.
250
High-impact chronic pain
is especially disruptive to multiple aspects of patients’ life, including their relationships, work, physical activity, sleep, self-care, and
self-esteem. Psychological interventions, following proper evaluation and diagnosis, can play a central role in reducing disability
in these patients. Furthermore, preliminary evidence indicates that psychological interventions administered prior to surgery have
been shown to reduce postsurgical pain and opioid use.
74,251
Behavioral health approaches as part of pain management should be considered a key component of the biopsychosocial model
and multidisciplinary pain management. These approaches aim to improve the overall pain experience and restore function by
addressing the cognitive, emotional, behavioral, and social factors that contribute to pain-related stress and impairment.
242,246,252
They target a variety of domains, including physical functioning, pain medication use, mood, cognitive patterns, and QOL.
242
Behavioral
Health
Approaches
Interventional
Procedures
Restorative
Therapies
Medications
(Opioid and
Non-opioid)
Complementary
& Integrative
Health
Individualized, Multimodal,
Multidisciplinary Pain Management
Figure 13: Behavioral Health Is One of Five Treatment
Approaches to Pain Management
2.5 BEHAVIORAL HEALTH APPROACHES
38 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
The following paragraphs briefly describe behavioral health approaches. This list is not inclusive or exhaustive but instead provides
examples of common behavioral health approaches.
Behavioral therapy (BT) for pain focuses largely on applying the principles of operant conditioning to identify and reduce
maladaptive pain behaviors (e.g., fear avoidance) and increase adaptive or “well” behaviors. This improvement is achieved by
minimizing reinforcement of maladaptive behaviors, providing reinforcement of well behaviors, and reducing avoidance behaviors
through gradual exposure to the fear-provoking stimuli (e.g., exercise). The overall goal of BT in the treatment of pain is to increase
function.
253,254
BT has demonstrated eectiveness for reducing pain behaviors and distress and for improving overall function, and
it can be more cost-eective than active physical treatment.
254,255
Cognitive behavioral therapy (CBT) aims to reduce maladaptive behavior and improve overall functioning. However, in addition
to focusing on altering behavioral responses to pain, CBT focuses on shifting cognitions and improving pain coping skills.
256
CBT
includes psychoeducation about the relationship between psychological factors (e.g., thoughts, feelings) and pain; cognitive
restructuring of maladaptive thought patterns; and training in a variety of pain coping strategies, including activity pacing
and pleasant activity scheduling.
242
CBT is eective for a variety of pain problems
257
and can help improve self-ecacy, pain
catastrophizing, and overall functioning.
258,259
The Agency for Healthcare Research and Quality (AHRQ) found that CBT can lead
to long-term improvements in patients with low-back pain and fibromyalgia.
260
Acceptance and commitment therapy (ACT) is a form of CBT that emphasizes observing and accepting thoughts and feelings,
living in the present moment, and behaving in a manner that serves an individual’s chosen values. Unlike traditional CBT
approaches, ACT focuses on creating psychological flexibility through acceptance of psychological and physical experiences
rather than by challenging them.
261,262
Mindfulness-based stress reduction (MBSR) is a mind-body treatment typically delivered in a group format. It focuses on
improving patients’ awareness and acceptance of their physical and psychological experiences through body awareness and
intensive training in mindfulness meditation.
263
Mindfulness meditation teaches patients to self-regulate their pain and pain-
related comorbidities by developing nonjudgmental awareness and acceptance of present-moment sensations, emotions,
and thoughts.
264,265
Research suggests that MBSR is an eective intervention for helping individuals cope with a variety of pain
conditions, including rheumatoid arthritis, low-back pain, and MS.
266,267
MBSR also has a positive impact on pain intensity, sleep
quality, fatigue, and overall physical functioning and well-being.
263,268–270
Emotional awareness and expression therapy (EAET) is an emotion-focused therapy for patients with a history of trauma or
psychosocial adversity who suer from centralized pain conditions.
271
In this approach, patients are taught to understand that
their pain is exacerbated or maintained by unresolved emotional experiences that influence neural pathways involved in pain.
Patients are taught to become aware of these unresolved experiences, which include suppressed or avoided trauma, adversity,
and conflict, and to adaptively express their emotions related to these experiences. Patients learn that control over pain can be
achieved through emotional awareness and expression. Enhancing the patient’s capacity to approach an experience rather than
inhibit or avoid important emotions and interpersonal interactions leads to increased engagement in life activities. Research
indicates that EAET has a positive impact on pain intensity, pain interference, and depressive symptoms.
272
Self-regulatory or psychophysiological approaches include treatments such as biofeedback, relaxation training, and
hypnotherapy. These approaches use the mind-body connection to help patients with pain develop control over their physiologic
and psychological responses to pain.
242
Biofeedback entails monitoring and providing real-time feedback about physiologic
functions associated with the pain experience (e.g., heart rate, muscle tension, skin conductance). The overall goal of biofeedback
is to improve awareness and voluntary control over bodily reactions associated with pain exacerbations.
273
Biofeedback training
has proven eective for chronic headache and migraine in adults and children.
274
Relaxation training and hypnotherapy involve
altering attentional processes and heightening the experience of physical and psychological relaxation. Relaxation training
is often used in conjunction with biofeedback to increase physiological awareness and enhance relaxation skills.
242
Both of
these approaches have empirical support in pain management.
275,276
Empirical evidence also supports the use of hypnotherapy
to manage cancer pain, low-back pain, arthritis, pain from SCD, temporomandibular joint pain, fibromyalgia, and other pain
conditions.
275
Similar to relaxation training, hypnotherapy induces an altered state of consciousness guided by a hypnotherapist
that focuses the individual’s attention to alter his or her experience of pain.
2.5 BEHAVIORAL HEALTH APPROACHES
39PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Behavioral health interventions can be eective in improving clinical outcomes for pain,
246,271,277
but treatment should be tailored
to address patient preferences and needs. This tailoring requires careful assessment of patients’ pain perceptions, cognitive
and emotional responses, coping skills, and social and environmental status.
278
It also requires accurate diagnosis of comorbid
psychosocial concerns.
2.5.1 Access to Psychological Interventions
Despite widespread understanding of the importance of psychological interventions in the management of pain, many patients
with pain receive inadequate care.
279,280
Many factors contribute to this problem, including clinical barriers (e.g., treatment
accessibility, knowledge gaps, provider attitudes), health care system-related barriers (e.g., cost and reimbursement issues), and
patient-related barriers (e.g., stigma, attitudinal variables). When access to providers and costs are limiting factors, evidence-based
low-cost and scalable approaches delivered through telehealth and internet technologies may provide a low-burden, eective
alternative to traditional treatment approaches.
73,281
Research suggests that brief telehealth and digitally delivered treatments allow
for broad patient access and yield outcomes similar to traditional in-person psychological interventions for chronic pain.
282
To further enhance patient acceptance and engagement in psychological treatment, patients and providers need to know
about psychological treatments. Health professionals should have sucient understanding of the biopsychosocial model of
pain and how to appropriately assess and refer patients for behavioral health treatment.
252,283
This can be accomplished by
improving training and education in pain management
26,284,285
and initiating public campaigns to reduce stigma and enhance
public awareness of the biopsychosocial aspects of pain.
286
As noted in other sections of this report, the lack of health insurance
coverage for psychological services has also been cited as a significant barrier to adequate pain management (see Section 3.4.2:
Insurance Coverage for Complex Management Situations). Both a need for trained pain psychologists and appropriate incentives
are required to fill the work gap. Although several organizations have identified policy recommendations to close gaps in access
to pain management services,
287,288
coverage barriers persist. These barriers continue to hinder patients’ access to skilled
behavioral health providers, integrated and multidisciplinary care, and (for OUD and SUD) co-morbid treatment, as required.
289–292
GAPS AND RECOMMENDATIONS
GAP 1: Access to evidence-based psychological and behavioral health approaches for treating chronic pain and mental health
comorbidities (e.g., PTSD, depression, anxiety, mood disorders, SUD) is limited by geography, reimbursement, and
education in primary care and specialty care settings.
RECOMMENDATION 1A: Increase access to evidence-based psychological interventions, including the full range
of treatment deliveries (e.g., in-person, telehealth, internet self-management, mobile applications, group sessions,
telephone counseling) and hub-and-spoke models.
Behavioral Health Approaches
to Pain Management
• Telehealth
• Mobile health (mHealth) apps
• Public awareness campaigns
• Educating PCPs about referring
to Behavioral Health specialists
• Improvements to coverage barriers
• Provider training to close workforce gaps
• Support Groups
Figure 14: Overcoming Barriers to Behavioral Health Approaches
2.5 BEHAVIORAL HEALTH APPROACHES
40 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
RECOMMENDATION 1B: Educate physicians, dentists, and health care providers on the benefits of psychological
and behavioral health treatment modalities in the multidisciplinary approach to acute and chronic pain management.
RECOMMENDATION 1C: Improve reimbursement policies for integrated, multidisciplinary, multimodal
treatment approaches that include psychological and behavioral health interventions through traditional and
nontraditional delivery methods (e.g., in-person, telehealth, internet self-management, mobile applications,
group sessions, telephone counseling).
2.5.2 Patients With Chronic Pain as well as Mental Health and Substance Use Comorbidities
The occurrence of pain and mental health comorbidities, including depression, PTSD, and SUD, is well documented.
293–297
Psycho-social distress can contribute to pain intensity, pain-related disability, and poor response to treatment. Untreated
psychiatric conditions and current or historical SUD also increase the risk of both unintentional and intentional medication
mismanagement, OUD, and overdose.
298
Given the intersection between psychiatric/psychological symptoms and chronic pain,
it is important that the behavioral health needs of patients with pain be appropriately and carefully evaluated and treated with
the concurrent physical pain problem.
Although the literature exploring the eectiveness of interventions for patients with painful conditions and comorbid psychiatric
concerns is limited, research suggests that regular monitoring and early referral and intervention can improve pain and
psychiatric outcomes and prevent negative opioid-related outcomes.
74,242,290,299
Many CBPs recommend screening and regularly
monitoring the psychological health concerns and substance misuse risk of all patients with pain, using multidisciplinary
approaches and referring patients to behavioral health and substance use specialists as clinically indicated (see Section 3.1.2:
Screening and Monitoring).
40,300
Technological advances in the delivery of clinical tools (e.g., mobile applications) may improve
assessment, monitoring, and treatment delivery,
301
although further research is needed.
GAPS AND RECOMMENDATIONS
GAP 1: CBPs for chronic pain do not adequately address how to treat individuals with comorbid psychological health concerns.
RECOMMENDATION 1A: Screen for psychological health and SUDs in patients with acute or chronic pain, and
consider early referral to behavioral health providers when clinically indicated.
RECOMMENDATION 1B: Use an integrated multidisciplinary approach that may include existing evidence-based
psychological and behavioral interventions (e.g., CBT, coping skills, stress reduction, mindfulness-oriented recovery)
to address chronic pain when clinically indicated.
RECOMMENDATION 1C: Refer patients to both pain and addiction specialists when OUD is suspected, and ensure
an integrative approach to health care.
RECOMMENDATION 1D: Buprenorphine may be considered appropriate for pain treatment in this population
when clinically indicated.
RECOMMENDATION 1E: When considering buprenorphine and other opioids, use the lowest eective dose in
conjunction with non-opioid treatment modalities, with enhanced monitoring and collaboration with addiction
specialists. Conduct regular reevaluation and assessment, with a treatment plan and established goals, to
achieve optimal patient outcomes.
GAP 2: Many CBPs for chronic pain do not adequately address barriers to acceptance of psychological treatments.
RECOMMENDATION 2A: Enhance and inform patient, clinician, and public understanding of the importance of a
biopsychosocial model approach for chronic pain conditions.
GAP 3: Research gaps exist in the eectiveness of existing psychological interventions for the treatment of psychological
health and substance use in the subpopulation of patients with chronic pain and psychological health comorbidities.
2.6 COMPLEMENTARY AND INTEGRATIVE HEALTH
41PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
RECOMMENDATION 3A: Conduct research on the applications and indications of existing evidence-based
psychological health interventions for patients with chronic pain and psychological health or substance
use comorbidities.
RECOMMENDATION 3B: Conduct research on the ecacy of novel and innovative psychological and behavioral
health treatments (e.g., biofeedback, hypnosis, relaxation therapies).
GAP 4: There has not been sucient validation of mobile and electronic health applications (apps) used for clinical treatment of
patients with pain with comorbid psychological conditions.
RECOMMENDATION 4A: Conduct peer-reviewed validation research to guide the use of mobile and electronic
health (e health) applications within the context of the biopsychosocial treatment modalities for chronic pain.
RECOMMENDATION 4B: Add a category for electronic and mobile treatments to the Substance Abuse and Mental
Health Services Administration’s (SAMHSA’s) Evidence-Based Practices (EBP) Resource Center and a designation for
pain for target audiences when evidence of benefit exists.
RECOMMENDATION 4C: Establish a validation process for apps used for biopsychosocial treatments to
better inform physician, provider, and patient users of these apps that are evidence-based and eective for the
management of various chronic pain syndromes.
Behavioral
Health
Approaches
Interventional
Procedures
Restorative
Therapies
Medications
(Opioid and
Non-opioid)
Complementary
& Integrative
Health
Individualized, Multimodal,
Multidisciplinary Pain Management
Figure 15: Complementary and Integrative Health Is One of
Five Treatment Approaches to Pain Management
2.6 COMPLEMENTARY AND INTEGRATIVE HEALTH
Clinical best practices may recommend a collaborative, multimodal, multidisciplinary, patient-centered approach to treatment
for various acute and chronic pain conditions to achieve optimal patient outcomes. For improved functionality, activities of
daily living, and quality of life, clinicians are encouraged to consider and prioritize, when clinically indicated, nonpharmacologic
approaches to pain management.
54,302–307
Complementary and integrative health approaches for the treatment or management
of pain conditions consist of a variety of interventions, including mind-body behavioral interventions, acupuncture and massage,
osteopathic and chiropractic manipulation, meditative movement therapies (e.g., yoga, tai chi), and natural products.
308
The National Institutes of Health (NIH) National Center for Complementary and Integrative Health defines “complementary
approaches” as those nonmainstream practices that are used together with traditional medicine; it defines “alternative
approaches” as those used in place of conventional medicine, noting that most patients who use nonmainstream approaches
do so with conventional treatments.
309
There are many definitions of “integrative” health care, but all involve bringing together
conventional, complementary, and integrative health approaches in a coordinated way.
2.6 COMPLEMENTARY AND INTEGRATIVE HEALTH
42 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
The current opioid crisis has spurred intense interest in identifying eective nonpharmacologic approaches to managing pain.
The use of complementary and integrative health approaches for pain has grown within care settings across the United States
over the past decades. As with other treatment modalities, complementary and integrative health approaches can be used as
stand-alone interventions or as part of a multidisciplinary approach, as clinically indicated and based on patient status. Examples
of complementary and integrative health approaches to pain include acupuncture, hands-on manipulative techniques (e.g.,
osteopathic or chiropractic manipulation, massage therapy), mindfulness, yoga, tai chi, biofeedback, art and music therapy,
spirituality, and the use of natural or nutritional supplements. These therapies can be provided or overseen by licensed
professionals and trained instructors. The use of complementary and integrative health approaches should be communicated to
the pain management team.
Overall, most complementary and integrative health approaches can provide improved relief, when clinically indicated, when
used alone or in combination with conventional therapies such as medications, behavioral therapies, and interventional
treatments, although more research to develop evidence-informed treatment guidelines is needed.
308
Improved reimbursement policies for complementary and integrative health approaches as well as improved education for
medical professionals and a greater workforce of pain management specialists can address key barriers to acceptance and
implementation of complementary and integrative health approaches for pain.
308
Additional research, greater patient and
clinician education — including clinical guidance and indications for use — and expanded coverage of complementary and
integrative health approaches are essential for a comprehensive solution to reduce the reliance on opioids.
The following paragraphs briefly describe complementary and integrative health approaches, which can be considered
singularly or as part of a multimodal approach to the management of chronic and acute pain, depending on the patient and his
or her medical conditions. This list is not inclusive or exhaustive but instead provides examples of common complementary and
integrative health approaches.
I joined the Marines in 2005 and was deployed to Afghanistan. In 2009, my team was hit by
an IED. I was about 10 feet away and it launched me in the air. I sustained numerous shrapnel
injuries. My right arm was ripped open down to my hand and I had some shrapnel in both of
my legs and my left arm. Overall, I had 26 surgeries over 3 1/2 years in the hospital, where I
started receiving alternative therapy.
After I got out of being an inpatient, I told myself I was going to get o of all my meds and I
did that. I watched too many fellow service members, comrades, turn into zombies just being
pumped full of medications. It was not something that I wanted to do with my life.
So I wanted to try something new. I tried acupuncture and it seemed to work very well.
Recently I received a di erent type of therapy called digital medicine. I was having some pain
in my foot. If my foot stays down for a long period of time, it gets swollen, and I have limited
feeling from my left knee down to my foot. I went through a form of visual and audio therapy
and somehow that triggered those nerves to kick back in. Within 15 minutes, I had regained
feeling in my leg and foot. It was a 30-minute session. We did three sessions. That lasted for
about a month. It’s not forever, but in my opinion it beats taking medications.
I think a combination of acupuncture and digital medicine is, in a sense, the way of the future.
That’s what I’ve been doing and it’s worked for me and it’s worked for many other people.
CORY’S
STORY
PATIENT TESTIMONIAL
2.6 COMPLEMENTARY AND INTEGRATIVE HEALTH
43PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Acupuncture is a recognized form of therapy that has its origins in ancient Chinese medicine. It involves manipulating a system
of meridians where “life energy” flows by inserting needles into identified acupuncture points. An estimated 3 million American
adults receive acupuncture each year.
310
It is generally considered safe when performed by a licensed, experienced, well-trained
practitioner using sterile needles, and although there are risks as with any intervention, the risks are minimal. The therapeutic value
of acupuncture in the treatment of various pain conditions, including osteoarthritis; migraine; and low-back, neck, and knee pain
has growing evidence in the form of systematic reviews and meta-analyses.
311–318
Existing CPGs concerning the use of acupuncture
for pain are inconsistent and often dier regarding the evidence-based science and accepted mechanisms by which acupuncture
has persisting eects on chronic pain.
54,302–307,314,319–322
As with all medicine, a risk-benefit analysis, consideration of clinical
indications, and patient acceptance need to be considered.
Massage and manipulative therapies, including osteopathic and chiropractic treatments, are commonly used for pain
management. Such interventions may be clinically eective for short-term relief
323,324
and are best accomplished in consultation
with the primary care and pain management teams. Studies on massage have considered various types, including Swedish, Thai,
and myofascial release, but these studies do not provide adequate details of the type of massage provided. Systematic reviews
note that the few studies looking at the eect of massage on pain use rigorous methods and large sample sizes.
157,325
Other
reviews recognize positive clinical eects on various pain conditions, including postoperative pain; headaches; and neck, back,
and joint pain.
326–329
MBSR, also discussed above in the Behavioral Health Approaches section, is a program that incorporates mindfulness skills
training to enhance one’s ability to manage and reduce pain. Mindfulness enables an attentional stance of removed observation
and is characterized by concentrating on the present moment with openness, curiosity, and acceptance. This approach allows
for a change in one’s point of view on the pain experience. Studies support statistically significant beneficial eects for low-back
pain.
330,331
A meta-analysis demonstrated that mindfulness meditation significantly reduces the intensity and frequency of primary
headache pain.
332
Yoga, a practice rooted in ancient Hindu tradition and a way of life that incorporates mind, body, and a spiritual approach, has
shown improved outcomes for a variety of medical and nonmedical conditions. Yoga has become popular in Western cultures as
a form of mind and body exercise that incorporates meditation and chants. Yoga’s use of stretching, breathing, and meditation has
also been therapeutic in the treatment of various chronic pain conditions, especially low-back pain.
333–337
Although there have been
limited reports of pain symptoms becoming more severe with yoga, overall, the risk-benefit analysis suggests that yoga is generally
safe, beneficial, and cost-eective, especially when administered in the group setting.
338
Tai chi originated as an ancient Chinese martial art used to balance the forces of yin and yang. Modern tai chi has become popular
for core physical strengthening through its use of slow movements and meditation. It has demonstrated long-term benefit in
patients with chronic pain caused by osteoarthritis and other musculoskeletal pain conditions.
339,340
Like yoga, tai chi appears to be
safe; demonstrates positive results, especially over the long term; and can also be cost-eective in the group setting. Both yoga
and tai chi can be delivered remotely via telemedicine/telehealth.
Complementary and
Integrative Health
Massage &
Manipulative
Therapies
Spirituality
Yoga
Tai Chi
Acupuncture
Mindfulness-
Based
Stress Reduction
This list is not exhaustive
Figure 16: Complementary and Integrative Health Approaches for the Treatment
or Management of Pain Conditions Consist of a Variety of Interventions
2.7 SPECIAL POPULATIONS
44 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Spirituality is a broad concept and generally includes a sense of connection to something bigger than the individual. It typically
involves a search for meaning in life. Spiritual or religious beliefs can influence a person’s lifestyle, attitudes, and feelings about
pain. People living with pain may use religious or spiritual forms of coping, such as prayer and meditation, to help manage their
pain. Growing evidence indicates that spiritual practices and resources are beneficial for people with pain.
341
As a result, clinicians
may consider the role of spirituality in pain management.
GAPS AND RECOMMENDATIONS
GAP 1: A large variety of complementary and integrative health approaches are often overlooked in the management of pain.
RECOMMENDATION 1A: Consider complementary and integrative health approaches, including acupuncture,
mindfulness meditation, movement therapy, art therapy, massage therapy, manipulative therapy, spirituality, yoga, and
tai chi, in the treatment of acute and chronic pain, when indicated.
RECOMMENDATION 1B: Develop CPGs for the application of complementary and integrative health approaches for
specific indications.
GAP 2: There is a gap in the understanding of complementary and integrative health approaches.
RECOMMENDATION 2A: Conduct further research on complementary and integrative health approaches to
determine their therapeutic value, risk and benefits, and mechanisms of action.
RECOMMENDATION 2B: Consider the inclusion of various complementary and integrative health approaches as
part of an integrated approach to the treatment of chronic pain.
RECOMMENDATION 2C: Conduct further research on nutritional supplements such as alpha lipoic acid, L-carnitine
transferase, and vitamin C and their eect on acute and chronic pain management.
2.7 SPECIAL POPULATIONS
Painful conditions and pain management are complex in part because various populations have unique issues that aect acute
and chronic pain. Special populations in pain management that the Task Force identified include children, older adults, women,
pregnant women, individuals with SCD, individuals with other chronic relapsing pain conditions, racial and ethnic minority
populations, active duty service members and Veterans, and patients with cancer and those in palliative care. The special
populations section in this report was included to highlight several special populations’ considerations for pain management. The
populations highlighted here are not exhaustive, and the special populations section on chronic relapsing conditions is intended
to serve as a general category that applies to many painful conditions not specifically mentioned. No special population was
purposefully excluded from the report.
2.7.1 Unique Issues Related to Pediatric Pain Management
Chronic pain is estimated to aect 5% to 38% of children and adolescents.
342–344
These pain conditions can be from congenital
diseases (e.g. sickle cell disease), where pain begins in the infant or toddler age period; chronic noncongenital diseases (e.g.,
juvenile idiopathic arthritis, fibromyalgia, inflammatory bowel disease); or primary chronic pain conditions (e.g., headaches,
chronic abdominal pain, chronic musculoskeletal pain, CRPS). The origin of pain conditions in the pediatric age group is
important because the developing pediatric nervous system can be especially vulnerable to pain sensitization and development
of neuroplasticity.
345
Data support the finding that early neonatal and childhood pain experiences can alter pain sensitivity
in later life.
346
Poor pain management in children can put them at risk for persistent pain and increased impairment as they
transition into adulthood and may even be linked to the development of new chronic pain conditions.
347,348
The application of
the biopsychosocial model to pediatric pain care is therefore vital. Psychological conditions resulting from chronic disease
and pain syndromes can contribute to long-term pain. These psychological conditions can include diculty coping, anxiety,
and depression. Incorporation of parents and family into pain care is especially important in the pediatric population because
childhood pain can be aected by family and parental factors, including family functioning and parental anxiety, and depression.
2.7 SPECIAL POPULATIONS
45PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Appropriate pain management in childhood is imperative because children’s early pain experiences can shape their response
to pain as adults. Overall, there is a substantial need for more trained pediatric pain specialists to address the often complex
aspects of pediatric pain. There is a greater challenge in attracting top physicians to further specialize in pediatric pain
fellowships, and this aspect of medical education would address an ongoing gap in this area. It is of utmost importance to
introduce comprehensive pain care early in the pediatric age group to optimize patients’ QOL now and in the future.
349
GAPS AND RECOMMENDATIONS
GAP 1: The significant shortage of pediatric pain specialists and comprehensive pain service centers presents a barrier to
addressing the needs of pediatric patients with acute and chronic pain. This limited access is further compromised
by lack of reimbursement and coverage for services related to comprehensive pain management, including
nonpharmacologic evidence-based pain therapies.
RECOMMENDATION 1A: Increase access to pediatric pain services with pain expertise, which can likely be
achieved through an increase in the workforce and novel care delivery models.
RECOMMENDATION 1B: Deliver and appropriately reimburse and cover pediatric pain care in the context of
comprehensive, multidisciplinary treatment.
GAP 2: Pediatric patients with chronic pain conditions eventually transition to adult care, during which time they may experience
gaps in care, increased health care utilization, poor patient outcomes, and other health care vulnerabilities and morbidities.
RECOMMENDATION 2A: Develop models of care for appropriate transition for pediatric patients with acute or
chronic pain conditions to ensure seamless care delivery as well as decreased morbidity and mortality.
GAP 3: Most physician pain specialists are not credentialed in pediatric pain and therefore are not permitted by their institutions to
take care of children with chronic pain.
RECOMMENDATION 3A: Encourage and assist pain physicians in obtaining the necessary training for credentialing
in pediatric pain. This is a significant step toward improving pediatric patient access.
GAP 4: Many current CBPs do not address pediatric opioid prescribing best practices. Further, RCTs and real-world evidence of
non-opioid pharmacologic therapies in pediatric patients for chronic pain are lacking.
RECOMMENDATION 4A: Develop pediatric pain management guidelines that address appropriate indications for
opioids and responsible opioid prescribing.
RECOMMENDATION 4B: Conduct pediatric pain research to inform national guidelines using multimodal
approaches to optimize pain management for children and adolescents.
2.7.2 Older Adults
Chronic pain is one of the most common, costly, and incapacitating conditions in older adults.
350
Managing pain in older adults can
be complex because of age-related physiologic changes, associated medical and mental health comorbidities, polypharmacy,
increases in pain thresholds, decreases in pain tolerance, and alterations in pharmacokinetics and pharmacodynamics that
increase the risk of side eects from pharmacologic treatment.
304,351
Eective pain management for older adults requires an
understanding of the special considerations associated with the physiology of aging, validated assessment tools, common pain
presentations in the older adult population,
352
and the use of evidence-informed CPGs for common conditions such as low-back
pain.
353
Older patients may have increased risk of GI bleeding and renal damage from NSAIDs.
2.7 SPECIAL POPULATIONS
46 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: There is a need for opioid prescribing guidelines for the aging population that provide the potential for increased risk of
falls, cognitive impairment, respiratory depression, organ metabolism impairment, and age-related and non-age-related
pain issues.
RECOMMENDATION 1A: Develop pain management guidelines for older adults that address their unique
risk factors. However, a risk factor of a medication should not necessarily be an automatic reason not to give
this medication to an elderly patient. Clinicians must assess the risk versus benefit of using medications while
considering other modalities in this patient population.
RECOMMENDATION 1B: Consider using a multidisciplinary approach with nonpharmacologic emphasis given the
increased risk of medication side eects in this population.
RECOMMENDATION 1C: Establish appropriate pain management education for physicians and health care
providers who treat older adults.
2.7.3 Patients with Cancer-Related Pain and Patients in Palliative Care
Cancer pain aects millions of Americans.
306,354
In addition, there are more than 14 million cancer survivors in the United
States as a result of remarkable advances in cancer diagnosis and therapy. An estimated 40% of cancer survivors
continue to experience persistent pain as a result of treatments such as surgery, chemotherapy, and radiation therapy.
Persistent pain is also common and significant in patients with a limited prognosis, as often encountered in hospice and
palliative care environments.
355
GAPS AND RECOMMENDATIONS
GAP 1: These patient populations are frequently managed by practitioners who do not specialize in pain or palliative care. Many
oncologists and primary care physicians are not trained to recognize or treat persistent pain associated with cancer or
other chronic medical problems with limited prognosis.
RECOMMENDATION 1A: Clinicians should assess and address pain at each patient encounter. Causes of pain such
as recurrent disease, second malignancy, or late-onset treatment eects should be evaluated, treated, and monitored.
GAP 2: Patients with persistent pain associated with cancer and/or cancer treatment or other chronic medical problems with
limited prognosis in palliative care often receive less optimal care with restricted treatment modalities.
RECOMMENDATION 2A: When clinically indicated, use multimodal and multidisciplinary treatment as part of
cancer-related pain management and palliative care.
2.7.4 Unique Issues Related to Pain Management in Women
Central to the unique issues women face in pain management are the dierences between men and women with respect
to pain sensitivity, response to pain medication, and predisposition to clinical pain conditions.
356
Data and recent literature
suggest that women experience more pain than men, have greater sensitivities to painful stimuli compared with men, and report
experiencing more intense pain.
357,358
In addition to the response to pain medication, there exist sex dierences in the patterns
of nonmedical use and abuse of prescription opioids.
359,360
Research has identified that women are more likely than men to
misuse prescription opioids.
361
Furthermore, from 1999 to 2010, the percentage increase in opioid-related overdose deaths was
greater in women than in men.
362
Finally, women face unique pain management challenges in the pregnancy and postpartum
periods. To mitigate the heightened risk associated with pain management in these periods, it is important to emphasize the
importance of obstetricians and gynecologists (OB-GYNs) on the multidisciplinary pain management team.
2.7 SPECIAL POPULATIONS
47PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: Women face unique challenges regarding their physical and mental health, interactions with the health care system,
and roles in society. Women use the health care system as patients, caregivers, and family representatives and can
be particularly aected by costs, access issues, and gender insensitivity from health care providers and sta. Several
diseases associated with pain — in particular, chronic high-impact pain — have a higher prevalence in women or are
sex specific, including endometriosis, musculoskeletal and orofacial pain, fibromyalgia, migraines, and abdominal and
pelvic pain.
RECOMMENDATION 1A: Increase research to elucidate further understanding of the mechanisms driving sex
dierences in pain responses and research of mechanism-based therapies that address those dierences.
RECOMMENDATION 1B: Raise awareness in the public and health care arenas to the unique challenges
that women face during pregnancy and in the postpartum period, including various pain syndromes and
psychosocial comorbidities.
GAP 2: Women may experience increased pain sensitivity. Of note, OB-GYNs may be one of the first health care providers a
woman with pain encounters, yet they are not often included as part of a multidisciplinary care team.
RECOMMENDATION 2A: Include OB-GYNs as part of multidisciplinary care teams because they are likely to play
an important role in the treatment of pain for women.
2.7.5 Pregnancy
Managing pain in pregnant women is uniquely challenging because clinical decision making must account for the pregnant
mother and the developing fetus.
363
Further complicating pain management in the peripartum period is the lack of CPGs for
nonpharmacologic treatments that may decrease the potential adverse outcomes for newborns associated with opioid therapy,
such as neonatal abstinence syndrome. Greater research into chronic pain management in pregnancy is needed.
364–366
GAPS AND RECOMMENDATIONS
GAP 1: There is a need for evidence-based CPGs for the use of analgesics during pregnancy and the postpartum period.
RECOMMENDATION 1A: Improve evidence for pain management of pregnant and postpartum women with greater
research and innovation, in collaboration with the national specialty societies (the American College of Obstetricians
and Gynecologists, neonatologists, obstetricians, perinatal pediatricians, and other specialists).
RECOMMENDATION 1B: Counsel women of childbearing age on the risks of opioids and non-opioid medications in
pregnancy, including risks to the fetus and newborns.
2.7.6 Chronic Relapsing Pain Conditions
Chronic pain with periods of remission and frequent relapses defines “chronic relapsing pain conditions.” Examples of such
conditions include various degenerative, inflammatory, immune-mediated, rheumatologic, and neurologic conditions such as
MS, trigeminal neuralgia, Parkinson’s disease, CRPS, porphyria, systemic lupus erythematosus, lumbar radicular pain, migraines,
and cluster headaches. Acute pain flares on top of the chronic pain condition can be a common occurrence that may aect daily
routines and overall functionality, resulting in additional morbidity and the need for comprehensive pain care.
2.7 SPECIAL POPULATIONS
48 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
2.7.7 Sickle Cell Disease
Sickle cell disease is a group of inherited disorders characterized by complex acute and chronic symptoms, including pain.
367
An estimated 90,000 people in the United States have SCD, which disproportionately aects minority populations, particularly
African Americans.
368
Acute pain episodes, or “pain crises,” associated with SCD are abrupt in onset and unpredictable, and
they drive patients to seek care in the ED and inpatient unit, with estimated health care costs of almost $2 billion per year.
369,370
Chronic, severe, daily pain also occurs in approximately 30% to 40% of adolescents and adults with SCD, significantly impairing
their functioning and increasing in incidence and severity with age.
371–373
Pain in SCD is unique in that it occurs throughout the
patient’s lifespan, from infancy to adulthood, and develops directly from the disease.
374
The biology of SCD pain is complex and
varied; it likely arises from multiple mechanisms depending on whether an individual is suering from acute or chronic pain.
375
Pulmonary,
376
orthopedic,
377
psychosocial,
378
and other comorbidities of SCD can also give rise to painful complications in adults
and children.
GAPS AND RECOMMENDATIONS
GAP 1: There is sometimes a lack of partnership between the disease specialist (i.e., the hematologist, oncologist,
rheumatologist, or neurologist) and providers of comprehensive multidisciplinary pain programs.
RECOMMENDATION 1A: Provide referrals to a comprehensive pain program early in the course of the chronic
disease (e.g., MS, porphyria, systemic lupus erythematosus, migraine, Parkinson’s disease, neuropathic pain
syndromes) to determine the optimal approach to managing acute or chronic pain exacerbations, including potential
non-opioid, alternative therapies and nonpharmacologic therapies. Establish a partnership between the disease
specialist (e.g., the hematologist, oncologist, neurologist, or rheumatologist) and the pain team to optimize care.
My name is Anne. I’m a 19-year-old girl and college sophomore. I have struggled with sickle-
cell disease my whole life. My dad always told me that sickle cell does not have me — I have
sickle cell. I have learned to persevere through the pain.
I found that my passions were the one thing that kept the pain away. Even though I would be
in pain, I would still go out and dance. I would still sing. I was even a cheerleader at one point.
I think that with sickle cell, it’s also about what you can handle mentally.
I struggled with depression for a while and as recently as last February, I went through a
period of depression. It was the hardest thing, but I kept telling myself, OK Anne, you’re going
to get better. Just keep pushing. Just keep pushing.
I have been through six surgeries in my 19 years. I have had brain surgery due to Chiari I
malformation from sickle cell, which caused multiple migraines every day. I was shocked
because I would still go to school. I would still get my homework done. I would still go out and
have fun with my friends, even though I was still going through all this pain.
My brother told me that I am one of the strongest people he’s ever met. And that was so
touching because at that time I didn’t believe I was a strong person. It was hard because my
parents never dealt with a child with sickle cell. I’m their last child. And I’ve seen them cry. I’ve
seen them persevere with me.
My family is one thing that keeps me going; I can’t let anything stop me. I can’t even let one
little crisis stop me. I barely go to a hospital for my crisis now because I try to fi nd ways at
home to get rid of my pain.
ANNE’S
STORY
PATIENT TESTIMONIAL
2.7 SPECIAL POPULATIONS
49PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: There is a lack of evidence-based management guidelines for the treatment of acute and chronic pain in children and
adults with SCD.
RECOMMENDATION 1A: Develop comprehensive, evidence-based guidelines for the treatment of acute and
chronic SCD pain in children and adults.
RECOMMENDATION 1B: Conduct research to understand underlying mechanisms of acute and chronic pain,
and develop mechanistic non-opioid pharmacologic therapies and nonpharmacologic approaches for SCD pain
management.
GAP 2: Unpredictable, episodic exacerbations of acute pain pose a challenge for SCD pain management, and the majority of
patients have failed non-opioid pain medications prior to presentation for acute care. Constraints on opioid treatment
duration can make individualization of pain management dicult. Further, limited access to oral opioids at home for the
treatment of unplanned acute pain can result in increased use of health care services that could have been avoided.
RECOMMENDATION 2A: Protect access to the appropriate and safe use of opioids for patients with SCD, with
consideration for exemption from prescribing guidelines and state prescribing laws that do not specifically address
patients with SCD because of the complex nature and mechanism of acute and chronic sickle cell pain.
RECOMMENDATION 2B: Consider the lowest eective dose of opioids to treat acute pain crises, and prescribe
within the context of close follow-up and comprehensive outpatient pain care.
RECOMMENDATION 2C: Develop an individualized approach to pain management that includes consideration of
opioid and non-opioid therapies, such as behavioral health strategies and multimodal approaches.
RECOMMENDATION 2D: Provide patient education on the risks and benefits of opioids.
GAP 3: The SCD patient population faces significant health care disparities that aect access to and delivery of
comprehensive pain care and mental health services. Further, stigma, negative provider attitudes, and perceived racial
bias are associated with SCD pain,
379,380
which may compromise care, thus leading to increased suering from pain and
pain care delivery.
381–385
RECOMMENDATION 3A: Develop comprehensive care delivery models for SCD pain management, including
collaborative partnerships among pain medicine, SCD specialists and advocates, and multidisciplinary teams.
RECOMMENDATION 3B: Develop outpatient infusion clinics/day hospitals for SCD pain management to decrease
reliance on the ED for pain treatment.
RECOMMENDATION 3C: Increase access to and reimbursement for mental health services for patients with SCD.
RECOMMENDATION 3D: Provide education focused on stigma, negative provider attitudes, and perceived racial
bias at all levels of health care to optimize delivery of pain treatment to patients with SCD.
2.7.8 Health Disparities in Racial and Ethnic Populations, Including African-Americans, Hispanics/
Latinos, American Indians, and Alaska Natives
Considerable evidence exists documenting health disparities in racial and ethnic minority populations, particularly substantial
disparities in the prevalence, treatment, progression, and outcomes of pain-related conditions.
386
These disparities in care are
attributed to factors related to social disadvantage as well as factors within health systems.
387
Health disparities contributing to
suboptimal pain management in these special populations may be related to such factors as barriers to accessing health care,
lack of insurance, discrimination, lack of a PCP, lack of child care, a lower likelihood to be screened or receive pain treatment,
and environmental barriers that impede eective self-management. Eective strategies and plans to address these issues
specifically in these disparate communities are necessary to address these gaps to improve patient outcomes.
2.7 SPECIAL POPULATIONS
50 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: Socioeconomic and cultural barriers may impede patient access to eective multidisciplinary care. Evidence exists of
racial and ethnic disparities in pain treatment and treatment outcomes in the United States, yet few interventions have
been designed to address these disparities. Lower quality pain care may be related to many factors, including barriers to
accessing health care, lack of insurance, discrimination, lack of a PCP, lack of child care, lower likelihood to be screened
or receive treatment, and environmental barriers that impede self-management.
RECOMMENDATION 1A: Develop intervention programs informed by the biopsychosocial model to reduce racial
and ethnic disparities in pain.
GAP 2: Research shows that ethnic minorities may have greater pain sensitivity and are at increased risk for chronic pain, yet
they remain underserved.
RECOMMENDATION 2A: Develop biopsychosocial interventions for pain that are scalable and culturally enhanced.
2.7.9 Military Active Duty, Reserve Service Members, and Veterans
The experience of pain is prevalent in military and Veteran populations.
388
Pain management can be complex in military
populations, who experience combat-related injuries (e.g., ballistic wounds, burns, overpressurization, blunt trauma) in
addition to complications from accompanying conditions such as post traumatic stress disorder and traumatic brain injury
(TBI), both of which are more prevalent in Veterans than in the civilian population.
48,389,390
Delayed pain treatment following
injury can increase the likelihood of acute pain becoming chronic pain in service members and Veterans.
48
As a Nation, we must do better in fulfilling our solemn obligation to care for all those who have served our country and to
improve the QOL of our Nation’s Veterans, many of whom have risked their lives to protect our freedom while deployed,
often multiple times, to areas of prolonged conflict. Veterans die by suicide at higher rates compared with civilians in the
United States.
391
Among Veterans, pain conditions are associated with an increased risk of suicide.
392
Clinicians can discuss
suicide risk with Veterans and recognize that public health approaches to suicide prevention include addressing pain.
GAPS AND RECOMMENDATIONS
GAP 1: Military active duty, reserve service members, and Veterans have unique physical and mental health challenges
related to their military service that contribute to the development of or exacerbate acute and chronic pain conditions.
Medical and mental health comorbidities such as TBI, PTSD, limb loss, and musculoskeletal injuries often interfere with
successful treatment outcomes. Assessment and treatment of pain conditions in active duty service members and
Veterans require military-specific expertise and a coordinated, collaborative approach between medical and mental
health providers.
RECOMMENDATION 1A: Physicians and clinical health care providers taking care of military service members and
Veterans, regardless of practice setting, should consider in their pain care plan prior military history and service-
related health factors that may contribute to acute or chronic pain, as relevant to the clinical presentation.
RECOMMENDATION 1B: Physicians and clinical health care providers should work collaboratively to deliver
comprehensive pain care that is consistent with the biopsychosocial model of pain.
RECOMMENDATION 1C: Conduct research to better understand the biopsychosocial factors that contribute to
acute and chronic pain in active duty service members and Veterans, with a focus on TBI, PTSD, other mental health
issues, and SUDs.
RECOMMENDATION 1D: Conduct studies to better understand the contributing factors predisposing these patients
to movement along the spectrum from acute to chronic pain.
2.7 SPECIAL POPULATIONS
51PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAP 2: The transition from active military service to Veteran status can be complicated. A multitude of factors may aect a
successful transition, including incomplete integration of EHRs and imposed changes or delays in access to primary
care, pain specialty, and mental health physicians and health care providers.
RECOMMENDATION 2A: The integration of the DoD and Veterans Health Administration (VHA) health systems is
important for eective and timely pain care. This integration should include coordination of the transition from active
duty to Veteran status and care coordination across the health care spectrum that includes a smooth transition to
primary care, mental health and pain specialty physicians, and health care providers.
GAP 3: Active duty, reserve service members, and Veterans increasingly receive care in the community (including care provided
through external payment systems and Department of Defense (DoD)- or VHA-purchased care). A fragmented health care
system results in lack of coordinated care in the community, within the Military Health System (MHS), and in VHA as well
as diering care standards (such as the implementation of opioid risk-mitigation strategies). Within MHS, access to primary
care and specialty care — and multidisciplinary pain specialty care in particular — is dicult for some Veterans because of
geographical factors, limited availability of providers, and the need for specialized pain care treatment.
RECOMMENDATION 3A: To improve care coordination across health care systems, streamlined access to medical
records and collaboration across systems are needed to provide more timely and eective pain care.
3
CROSS-CUTTING CLINICAL
AND POLICY BEST PRACTICES
53PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
3.1 RISK ASSESSMENT
The selection of the most appropriate medication-based treatment approach for an individual with pain involves a careful
analysis of risks and benefits. Risks of side eects and toxicity must be balanced against the benefits, including improved
function with improved QOL, ADLs, and ability to work, as well as with improvement in medical condition. Clinicians evaluating
pain, whether acute or chronic, must conduct a thorough history, physical exam, and risk assessment, especially when
considering medications such as opioids in the treatment plan. Identifying patients at risk of SUD will help minimize potential
adverse consequences and facilitate treatment or referral for treatment of active SUDs.
Low
Risk
Medium
Risk
High
Risk
Patient
History
Biopsychosocial
Approach
Risk
Assessment
Deliberation and discussion
Physical
Examination
Diagnostic Screening
Tools and PDMP
Figure 17: A Risk Assessment Is Critical to Providing the Best Possible
Patient-Centered Outcome While Mitigating Unnecessary Opioid Exposure
3.1.1 Prescription Drug Monitoring Programs
Prescription drug monitoring programs (PDMPs) are state-managed electronic databases of controlled substances dispensed
(typically schedule II-IV drugs), with the majority of the data being reported by community-based pharmacies.
393
PDMPs enable
prescribers and pharmacists (and in some states, insurers, researchers, and medical licensing boards) to access the data,
monitor use by patients, monitor prescribing practices by practitioners, and check population-level drug use trends. Forty-nine
states and most of Missouri and the District of Columbia have operational PDMPs.
394,395
Prescribers may be required to use PDMP data at the point of care, enabling them to identify patients who have had multiple
provider episodes or potentially overlapping prescriptions that place them at risk. PDMPs can support safe prescribing and
dispensing practices and help curb opioid prescription by detecting patterns that can alert clinicians to patients who may be at
risk of an SUD. PDMPs can alert clinicians to provide potentially lifesaving information and interventions. The information found
in the PDMP can prompt the clinician to take action to improve patient safety by having a conversation about safety concerns
and understanding the patient’s goals and needs. Providers who identify uncertain medication behavior can respond clinically,
3. CROSS-CUTTING CLINICAL AND POLICY BEST PRACTICES
54 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
making referrals to mental health or substance abuse treatment.
396,397
McAllister et al.
398
found that all prescribers who were
surveyed indicated that accessing PDMP data altered their prescribing patterns. Caution is needed when using PDMPs as a tool
to aid in the proper dispensing of medications. However, PDMPs are not to be used as tools to stop dispensing medications
appropriately to those in need. For example, it is important for pharmacists to know that doctors often work as teams and to
ensure that the conclusion of inappropriate multiple provider use is made only after the pharmacist has communicated directly
with the prescribing clinician. Concerns that physicians, nurses, dentists, and pharmacies may have should be communicated
among one another or to the relevant state regulatory agencies, including state medical boards, nursing boards, dental boards,
and pharmacy boards, when appropriate.
PDMPs can assist in determining whether a patient is obtaining medications from multiple providers and filling prescriptions at
multiple pharmacies, especially when prescriptions are filled in quick succession or on the same day. As a tool to help inform
clinical decisions, PDMPs’ potential utility was highlighted in the CDC’s Guideline for Prescribing Opioids for Chronic Pain
Guideline.
399
Clinicians should consider reviewing PDMP data when starting patients on opioid therapy and periodically during
chronic opioid treatment.
399
Prescribers are more likely to use PDMPs that present data in real time, are used by all prescribers, are technically easy to
use without time constraints, and actively identify potential problems such as multiple prescribers or multiple prescriptions.
400
Requiring PDMP checks also has a positive eect. Buchmueller and Carey
401
found stronger eects when providers are
required to access the PDMP, and PDMPs significantly reduced measures of misuse in Medicare Part D. In contrast, they found
that PDMPs without such provisions had no eect. PDMPs can also bolster provider confidence. For example, in one study, ED
providers report feeling more comfortable prescribing controlled substances when they receive information from a PDMP.
398
Baehren et al.
402
found that when PDMP data were used in an ED, 41% of cases had altered prescribing after the clinician
reviewed PDMP data, with 61% of the patients receiving fewer or no opioid pain medications than the physician had originally
planned prior to reviewing the PDMP data and 39% receiving more opioid medication than previously planned because the
physician was able to confirm that the patient did not have a recent history of controlled substance use. The eective use of
PDMP data is beneficial to both health care professionals and patients.
The need to modernize and enhance the functionality of PDMPs is widely acknowledged.
403–406
For example, Colorado favors
the integration of automatic queries and responses that obviate time-consuming manual data entry and also recommends
that PDMPs be optimized with improvements, links to ED registration, and data population in EHRs.
407
EHRs should work to
integrate PDMPs into their system design at minimal to no additional cost to providers (to eliminate barriers to accessing
PDMP data), especially when these data points are mandated. States should individually provide links to their PDMPs from
major, certified EHR platforms. Maryland also recommends enhanced user interfaces and interstate data sharing for PDMPs.
404
Provider PDMP adoption has been shown to fall when interoperability is low and use is not mandated.
408
Accessing PDMP
data also aects VA and IHS. VA physicians noted that incomplete or unavailable data was a significant barrier to increasing
PDMP use.
409
In 2016, HHS issued a policy requiring IHS prescribers to query the PDMP before prescribing opioids and
pharmacists to report their dispensing activity to the PDMP; it also directed IHS to ensure that memorandums of understanding
were signed with the appropriate state oces.
49,410
Links to and use of PDMPs varies across IHS service areas.
GAPS AND RECOMMENDATIONS
GAP 1: PDMP use varies greatly across the United States, with variability in PDMP design; the state’s health information
technology infrastructure; and current regulations on prescriber registration, access, and use.
RECOMMENDATION 1A: Consider checking PDMPs, in conjunction with other risk stratification tools, upon initiation
of opioid therapy, with periodic reevaluation.
RECOMMENDATION 1B: Provide clinician training on accessing and interpreting PDMP data.
RECOMMENDATION 1C: Clinicians should engage patients to discuss their PDMP data rather than making a
judgment that may result in the patient not receiving appropriate care. PDMP data alone are not error proof and
should not be used to dismiss patients from clinical practices.
3.1 RISK ASSESSMENT
55PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
RECOMMENDATION 1D: If already performed upon admission in the inpatient hospital setting, the health care team
should not be mandated to repeatedly check the PDMP if already performed upon admission and pending discharge.
RECOMMENDATION 1E: Conduct studies to better identify where PDMP data are best used (e.g., inpatient versus
outpatient settings). Adjust PDMP data use based on the findings of the recommended studies to minimize undue
burdens and overuse of resources (i.e., streamline PDMP data use).
RECOMMENDATION 1F: States are encouraged to have interoperability between PDMP and EHR platforms (Code
of Federal Regulations 170.315). EHR vendors should work to integrate PDMPs into their system design at minimal to
no additional cost or burden to providers (to eliminate barriers to accessing PDMP data), especially when these data
points are mandated.
RECOMMENDATION 1G: Enhance the interoperability of PDMPs across state lines to allow for more eective use,
along with consistent reporting to PDMP by the VA and military health system.
RECOMMENDATION 1H: Clinicians within and outside federal health care entities should have access to each
other’s data to ensure safe continuity of care.
RECOMMENDATION 1I: Allow access to PDMPs by all opioid prescribers.
RECOMMENDATION 1J: Encourage funding programs to link interstate PDMP programs to each other.
3.1.2 Screening and Monitoring
Screening and monitoring in pain management seek to identify and reduce the risk of substance misuse, abuse, and overdose
as well as improve overall patient care. Evaluations of patient physical and psychological history can screen for risk factors and
characterize pain to inform treatment decisions. Screening approaches include eorts to assess for concurrent substance use
and mental health disorders that may place patients at higher risk for OUD and overdose. This includes screening for drug
and alcohol use and the use of urine drug testing, when clinically indicated.
84,411
These approaches enable providers to identify
high-risk patients so that they can consider substance misuse and mental health interventions, ADFs, and education materials to
mitigate opioid misuse.
413
Screening tools can help clinicians identify risks and help determine which medication classes may be appropriate for the
patient, including for long-term opioid therapy. Eective screening can include single questions, such as, “How many times
in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”
413
Other validated
screening tools include the Drug Abuse Screening Test
414
and the Alcohol Use Disorders Identification Test.
415
Clinicians must
recognize the limits of screening tools in detecting prior or developing SUD or OUD.
Urine drug tests (UDTs) can provide information about drug use that the patient does not report, including not using prescribed
medications as intended and unreported drug use. UDTs can also potentially inform treatment decisions by assessing an
individual’s drug metabolism rate. However, according to a systematic review by Agency for Healthcare Research and Quality
(AHRQ), evidence demonstrating the eectiveness of UDTs for risk mitigation during opioid prescribing for pain is lacking.
416,417
UDT results can be subject to misinterpretation and may sometimes be associated with practices that can harm patients (e.g.,
stigmatization, inappropriate termination from care). Clinicians do not consistently use practices intended to decrease the risk
for misuse, such as UDTs
411
and opioid treatment agreements,
418
likely in part because of competing clinical demands, perceived
inadequate time to discuss the rationale for UDTs and order confirmatory testing, and feeling unprepared to interpret and
address results.
419
To mitigate the risks of prescription opioid misuse, medical societies, in conjunction with state and federal regulatory agencies,
have recommended specific risk-reduction strategies, including written treatment agreements for patients with chronic pain
who are prescribed opioids.
418
Pain agreements or treatment agreements can be useful in defining the responsibilities of the
patient and the provider, and they create a structure to guide and evaluate opioid use. The agreement should be viewed as an
opportunity for ongoing dialogue about the risks of opioids and what the patient and clinician can expect from each other.
363
The agreement should not be about simply getting a form signed or a means to “fire” a patient for breaking the terms of the
agreement; rather, it is a tool for facilitating a conversation between the clinician and the patient.
418
3.2 STIGMA
56 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Monitoring approaches should be applied transparently and consistently in a manner that emphasizes safety so that
miscommunication and accidental stigmatization are minimized.
420
At follow-up, doctors should assess benefits in function,
pain control, and QOL using tools such as the three-item “average pain intensity (P), interference with enjoyment of life (E),
and interference with general activity (G)” or PEG scale
421
or asking patients about progress toward functional goals that have
meaning for them. Clinicians should also screen for factors that predict risk for poor outcomes and substance abuse, such as
sleep disturbance, mood disorder, and stress, either by using a pain rating scale such as the Defense and Veterans Pain Rating
Scale, which includes brief questions, or by routinely asking about these factors on clinical examination.
422
Clinicians should ask
patients about their preferences for continuing opioids, given their eects on pain and function relative to any adverse eects
they experience.
399
These factors illustrate the importance of health care providers having sucient time with the patient for a
thorough evaluation.
GAPS AND RECOMMENDATIONS
GAP 1: Comprehensive screening and risk assessment of patients are time-consuming but vital for proper evaluation of their
chronic pain conditions. Lack of sucient compensation for time and payment for services have contributed to barriers
in best practices for opioid therapy.
RECOMMENDATION 1A: Encourage CMS and private payers to provide sucient compensation for time and
payment for services to implement the various screening measures (e.g., extensive history taking, review of
medical records, PDMP query, urine toxicology screenings, when clinically indicated). These are vital aspects of risk
assessment and stratification for patients on opioids and other medications.
RECOMMENDATION 1B: Consider referral to pain, mental health, and other specialists, including addiction
medicine-trained physicians when high-risk patients are identified.
GAP 2: UDTs are not consistently used as part of the routine risk assessment for patients on opioids.
RECOMMENDATION 2A: Use UDTs as part of the risk assessment tools prior to the initiation of opioid therapy and
as a tool for reevaluating risk, using the clinical judgment of the treatment team.
RECOMMENDATION 2B: Clinicians should educate patients on the use of UDTs and their role in identifying both
appropriate and potentially inappropriate use.
GAP 3: Variability exists in what is included in opioid treatment agreements, which should be based on common principles and
reflect provider, practice, and patient demographics.
RECOMMENDATION 3A: Conduct studies to evaluate the eectiveness of the dierent components of opioid
treatment agreements. Treatment agreements should include the responsibilities of both the patient and the provider.
RECOMMENDATION 3B: Use opioid treatment discussions as an educational tool between providers and patients
to inform the patient about the risks and benefits of and alternatives to chronic opioid therapy.
3.2 STIGMA
Stigma associated with having chronic pain, especially when opioid therapy is used as a treatment modality, is a major concern
and has far-reaching eects on patients and all those involved in their care.
423
The dierent facets of stigma — at the patient,
provider, and social levels — collectively serve as a significant barrier to eective treatment of chronic pain.
424
There is a
growing body of empirical research into stigmatization and the resulting barriers to care. Studies suggest that patients who are
receiving or who have previously received long-term opioid therapy for nonmalignant pain face both subtle and overt stigma
from their family, friends, coworkers, the health care system, and society at large for their opioid treatment modality.
423–426
Compassionate, empathetic care in a provider-patient partnership is best for countering the stigma, isolation, and psychosocial
challenges of living with pain.
3.2 STIGMA
57PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
I have gone through, and exhausted
all of the other drug and non-drug
treatment options over the past 13
years. Still, I have pain. I hate that I
am being treated like a drug abuser
when I am just trying to make my life
more manageable on a daily level. I
try to participate in being part of our
family, making a contribution to
society, but it's hard. Not everyone
who needs pain relief is an abuser.
- April 2019
I understand the abuse of pain meds, but not all of
those who deal with chronic pain abuse them. I
have always abided by pain contracts, been willing
to submit UAS and yet still have had some pain
doctors treat me as an addict because of the number
of years I have been on pain meds. Trust is vital
between a pain patient and their physician.
- May 2018
How can a person be in pain for many years,
unable to do the things he or she used to do
without becoming depressed? Why does
everyone assume the person was depressed
or anxious first? Try having a serious heart
condition knowing if you go to an ER for
chest pain with or without extremely high
blood pressure they probably will think you
are seeking drugs
- June 2018
My wife has Cervical Spinal
Stenosis with Myelopathy. She
was forced to taper in January of
2018. Within one month she was
bed ridden and had talked to her
employer explaining why she
may have to quit her accounting
job. I can't tell you how
demoralizing this experience has
been. We were immediately
treated like second class citizens,
accused of seeking drugs and
the reason for the crippling, illicit,
drug epidemic taking place on
our streets.
- January 2019
I was sent to a doctor after
the last pain clinic in my
county closed. He yelled at
me, shamed me, and
dehumanized me right
in of front two other people.
- September 2018
STIGMA
Figure 18: Public Comments to the Task Force Arm the Barriers Stigma Creates
Feelings of guilt, shame, judgement, and embarrassment resulting from such stigma can increase the risk for behavioral health
issues, such as anxiety and depression, which can further contribute to symptom chronicity.
426
Reducing barriers to care that
exist as a consequence of stigmatization is crucial for patient engagement and treatment eectiveness.
424
Furthermore, the sub-population of patients with painful conditions and comorbid SUD face additional barriers to treatment
because of stigmatization of both chronic pain and addiction.
427
Chronic pain is common among individuals with SUD,
including opioid misuse,
428
yet stigma remains a significant barrier to implementation of programs and treatments for OUD,
such as medication-assisted treatment
429,430
and naloxone.
431
Patients with comorbid problematic opioid use and chronic
noncancerous pain report significant perceived stigma associated with methadone and buprenorphine treatment.
425
Clinicians
who treat acute and chronic pain, particularly with opioids, may experience stigma from colleagues and society in general
that — in addition to fear of scrutiny from state medical boards and the DEA — may also dissuade them from using opioids
appropriately. Clinicians are overburdened with time constraints, EHR demands, and other administrative tasks, which has
led to unprecedented levels of burnout among physicians. Stigma, combined with the enhanced time required to eectively
evaluate and treat pain, leads to over-referral and patient abandonment.
432
According to one study, only 12.2% of individuals
who require treatment for a SUD actually seek treatment. In addition, stigma is found to be a significant barrier, with 20.5%
not seeking treatment because of negative consequences associated with their work and around 17% being concerned about
negative judgements by friends or community.
432
3.2 STIGMA
58 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: Patients with chronic pain may face barriers in access to pain care due to being stigmatized as people seeking
medications to misuse. Contributing to this stigmatization are the lack of objective biomarkers for pain, the invisible nature
of the disease, and societal attitudes that equate acknowledging pain with weakness.
RECOMMENDATION 1A: Increase patient, physician, clinician, nonclinical sta, and societal education on the
underlying disease processes of acute and chronic pain to reduce stigma.
RECOMMENDATION 1B: Increase patient, physician, clinician, nonclinical sta, and societal education on the
disease of addiction.
RECOMMENDATION 1C: Counter societal attitudes that equate pain with weakness through an awareness
campaign that urges early treatment for pain that persists beyond the expected duration for that condition or injury.
RECOMMENDATION 1D: Encourage research aimed at discovering biomarkers for neurobiological mechanisms of
chronic pain.
GAP 2: The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are
being treated for pain. This confusion has created a stigma that contributes to barriers to proper access to care.
RECOMMENDATION 2A: Identify strategies to reduce stigma in opioid use so that it is never a barrier to
patients receiving appropriate treatment, with all cautions and considerations, for the management of their
chronic pain conditions.
Eight years ago, through a series of relatively minor events, I ended up with multiple
herniated and bulging disks in my lumbar and cervical spine and nerve-root impingement
in my neck. I also have two painful disc-spur complexes in my thoracic spine. This is how my
nightmare began.
I ended up going to multiple doctors to fi nd help for my pain — orthopedists, physiatrists, a
neurologist, and four top neurosurgeons. I was told that I was not a candidate for surgery, but
few other solutions were given.
I was accused of drug seeking, belittled for having a low pain threshold, which was not true,
and dismissed as a patient. I was unable to work and take care of my family because of the
constant pain. I was reduced to lying in bed, crying from the pain, and being emotionally
devastated. It was as if I had to prove my pain.
This was also the most vulnerable time for my family, who were my caregivers, because they
had no knowledge or understanding or tools to deal with me and my pain.
Understandably I became severely depressed. I had no prior psychiatric history and had
never been to a psychiatrist in my life. I was hospitalized three times for suicidal ideation.
Each time I would return home, but nothing had changed. My family didn’t know what to do to
help me and the situation caused a lot of family stress.
My doctors at the time didn’t help either. When I couldn’t stand the pain anymore, I went to
the ER several times and was treated like an addict. During one hospital stay, I was labeled
chemically dependent and recommended for a 30-day drug-rehabilitation program. I refused
to go because all I wanted was for the pain to stop and to go back to my normal life. About
two years later, I fi nally ended up in a pain management clinic headed by fellowship-trained
pain management anesthesiologists. I was treated with understanding and respect and given
the medical care that I needed to help improve my quality of life
JULIE’S
STORY
PATIENT TESTIMONIAL
3.3 EDUCATION
59PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
3.3 EDUCATION
Public, patient, provider, and policymaker education is critical to the delivery of eective, patient-centered pain management
and necessary for optimizing patient outcomes, promoting appropriate use of pain medication, and reducing the risk
associated with prescription opioids. This common theme is underscored across many federal reports, including the Institute
of Medicine’s (IOM’s) report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and
Research”; HHS’s National Pain Strategy; and other pain management and opioid-related consensus documents.
5,49,128,433
These reports consistently describe the extent to which pain and SUD education is insuciently covered in medical education
and training programs, which has a downstream impact on the extent to which patients are educated about pain and SUD.
Provider
Education
Policymakers,
Legistlators,
Regulators
Education
Public
Education
Patient
Education
+ Eective, patient-centered care
+ Optimize patient functional outcomes
+ Appropriate use of pain medication
+ Eliminate stigma
+ Reduced risk through risk-benefit assessment
Figure 19: Education Is Critical to the Delivery of Eective, Patient-Centered
Pain Care and Reducing the Risk Associated With Prescription Opioids
To begin to address the growing need for educational initiatives, multiple entities, including government agencies, nonprofit
organizations, pharmaceuticals manufacturers, academic institutions, and health systems, have developed and disseminated
pain- and opioid-related patient education programs, toolkits, pamphlets, and other interventions. Similarly, state-level
continuing education requirements have been established for several provider types (e.g., physicians, dentists, NPs, PAs,
pharmacists) that mandate education about appropriate opioid prescribing and dispensing. Addressing multiple education
gaps simultaneously will likely be necessary to optimize patient outcomes tied to public, patient, and provider education. Other
programs that could be considered are the development and eectiveness testing of a reimbursable pain self-management
training program that incorporates a pain educator, or evaluation of the role of a certified pain educator, in optimizing pain care
and improving patient education.
3.3.1 Public Education
The evidence base for public education about pain is limited. Whereas some evaluation of mass media campaigns for low-back
pain have been conducted in other countries, analyses in the United States are lacking.
434–436
The gaps and recommendations
specific to public pain education, as outlined below, that will inform best practices in public pain education are consistent with
those described elsewhere.
49
There is a significant need for improved public education on and understanding of the distinction
3.3 EDUCATION
60 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
between acute and chronic pain — notably, that chronic pain, regardless of its etiology, can become a chronic disease itself, with
measurable changes in the nervous system, spinal cord, and brain.
An estimated 50 million to 100 million people have chronic
pain, making it the most prevalent, costly, and disabling health condition in the United States.
5,6
Yet, despite its pervasiveness, it
remains largely unknown to the broader public.
GAPS AND RECOMMENDATIONS
GAP 1: National public education about pain is needed.
RECOMMENDATION 1A: Develop a national evidence-based pain awareness campaign that emphasizes the
public’s understanding of acute and chronic pain syndromes.
RECOMMENDATION 1B: Establish a mechanism to finance a large-scale, systematic, coordinated public campaign
to address pain awareness.
3.3.2 Patient Education
Patient education is another key component of any best practice model for outcomes. Patients benefit from a greater
understanding of their underlying disease process and pain triggers as well as knowing how to seek appropriate professional
care. It is important for patients to know that pain as a symptom is typically a warning of injury or disease that can aect the
body and mind. Finding the precipitating and perpetuating causes of the pain and addressing them with appropriate multimodal
therapy is considered the best management strategy for improving patient outcomes. It is also important for patients to
understand that pain can be a disease in its own right, particularly when pain becomes chronic and loses its protective function.
In this context, pain is often detrimental to the patient’s health, functionality, and QOL. A category of diseases is characterized
by chronic debilitating pain (e.g., trigeminal neuralgia, CRPS, postherpetic neuralgia). In such conditions, there is rarely a cure,
but appropriate assessment; accurate diagnosis; and patient-centered, multidisciplinary treatment can optimize pain relief,
improve function, and enhance QOL. Self-management skills training may include relaxation, pacing, cognitive restructuring,
maintenance planning, and relapse prevention.
42,43,47,437
Innovative delivery systems, including telehealth and other Web-based
applications, can oer technology-based education and self-management support to further engage and empower patients in
their care plan.
438–440
GAPS AND RECOMMENDATIONS
GAP 1: Current patient education is lacking for both acute and chronic pain.
RECOMMENDATION 1A: Prioritize access to educational tools for patients, families, and their caregivers that
include clinician visits, patient handouts, Web resources, and support groups to optimize patient outcomes.
RECOMMENDATION 1B: Explore and test innovative methods of delivering patient education and support
for patients with acute or chronic pain using technology, particularly in rural areas that have limited access to
multimodal treatment. Examples of means to provide patient access in such situations include telemedicine online
support groups, networks of in-person support groups with training and guidance from leaders, and applications
easily accessible on mobile devices.
GAP 2: Patient expectations for pain management in the perioperative arena are frequently not aligned with current surgical
practices or procedures that require pain management.
RECOMMENDATION 2A: During the preoperative visit, discuss pain control after surgery. This discussion should
be conducted by both the surgical team and the preoperative team.
RECOMMENDATION 2B: For major surgeries, use models such as the PSH or ERAS protocols to emphasize the
importance of patient education in the management of pain and rehabilitation activities.
3.3 EDUCATION
61PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
RECOMMENDATION 2C: CMS and private payers should recognize that the time spent educating and managing
patients’ expectations is cost-eective and provides a significant value that reduces the length of hospital stays
and improves patients’ postoperative pain management, allowing for faster recovery through earlier PT and
mobility that decreases the risk for postoperative complications (e.g., blood clots). CMS and other payers should
compensate according to physician-patient time spent.
GAP 3: Current educational materials and interventions for patients with chronic pain lack consistency, standardization, and
comprehensive information.
RECOMMENDATION 3A: Establish an online resource of evidence-informed educational materials for common
pain conditions and appropriate treatment modalities.
RECOMMENDATION 3B: Convene a chronic pain expert panel that includes experienced patients, patient
advocates, and clinicians to develop a set of core competencies and other essential information specific to patient
pain education. Provide grants for the creation of patient education programs and materials based on these core
competencies, and disseminate them widely to patients, their family, and caregivers through clinics, hospitals, pain
centers, and patient groups.
3.3.3 Provider Education
Experts have noted the benefits that could be realized from the development of a more comprehensive pain curriculum for
training and continuing education of providers.
15
Encouraging licensing and education practices that do more to emphasize
safe and eective pain assessment and management has the potential to improve pain management and mitigate factors that
contribute to the current opioid crisis.
26,441
Health care professionals who prescribe opioids are in a key position to balance the
benefits of analgesics against the risk of adverse clinical outcomes. It is estimated that “apart from federal prescribers who are
required to be trained, fewer than 20% of the over one million health providers licensed to prescribe controlled substances have
training on how to prescribe opioids safely and eectively.”
442
Providers can access educational resources, receive accreditation,
or renew existing licenses through public- or private-sector enterprises.
404
National stakeholders have recommended that
accrediting organizations develop, review, promulgate, and regularly update core competencies for pain care education,
licensure, and certification at the prelicensure (i.e., undergraduate professional) and postlicensure (i.e., graduate) levels.
49,291
Educational interventions for pain should be guided by core competencies and target both the training and practice levels.
26
Provider education research specific to patient outcomes is limited, but systematic reviews on continuing medical education
(CME) programs indicate that interventions that include multimedia, multiple instructional techniques, and multiple exposures
are associated with improved provider knowledge outcomes compared with alternatives (e.g., print materials, one-time
interventions).
443–445
Likewise, regardless of whether educational interventions are targeted at clinicians in training or in
practice, aligning educational interventions with core competencies (i.e., outcomes) for pain care education
15,441
is a best
practice.
49
In addition, although Frank et al.
446
demonstrated the eectiveness of a longitudinal distance learning approach
that uses telemedicine to change clinical pain practice in primary care (e.g., Extension for Community Healthcare Outcomes
[Project ECHO]), a recent systematic review by Rochfort et al.
447
found a scarcity of studies on the eectiveness of educational
interventions implemented by a PCP designed to promote optimal patient outcomes. Results do indicate that education and skills
training of PCPs may positively aect patient performance of self-management pain-reduction activities, improve patient lifestyle
behaviors, and increase perceived QOL. This finding underscores the importance of further training for health care professionals
in patient self-management support as part of patient-centered care and as a mechanism for improving pain outcomes.
Chronic Pain and Headache Management TeleECHO (ECHO Pain), with Project ECHO, is a telehealth approach that supports
clinicians’ education and training regarding treating patients with chronic pain and safe opioid management.
448
The model is
based on workplace learning, with cases selected by participants from their patient panels combined with short lectures by
experts (referred to as a “hub-and-spoke model”).
3.4 ACCESS TO PAIN CARE
62 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: Gaps exist in pain management understanding and education throughout the health care provider community. There is a
need for further education regarding acute and chronic pain for all health care providers in professional school curricula,
postgraduate education, and further clinical specialty training.
RECOMMENDATION 1A: Further develop biopsychosocial educational models for clinicians at all levels of training.
RECOMMENDATION 1B: Develop eective educational resources for PCPs to improve the current understanding and
knowledge of pain treatment modalities, initially available treatments, and early referral to pain specialists
RECOMMENDATION 1C: Explore intensive continuing pain education for PCPs, including telehealth, tele-mentoring,
and the Project ECHO model, as a means of providing pain education for PCPs by pain specialists. Consider the State
Targeted Response Technical Assistance Consortium model for pain training as it currently exists for addiction training.
GAP 2: Pain is generally treated as a symptom of another illness, disease, or injury; it is not commonly recognized as a separate
category of disease
5,449
The lack of education on pain syndromes and pain mechanisms limits the ability to recognize
chronic pain as a category of disease.
RECOMMENDATION 2A: The Task Force supports WHO’s recognition of chronic and acute pain as a category of
disease, with its revisions to the “International Classification of Diseases, 11th Revision.”
450
RECOMMENDATION 2B: Conduct further education on pain syndromes and mechanisms through clinician training,
such as CME, the Project ECHO model, tele-mentoring, and other continuing education programs.
3.3.4 Policymaker, Regulator and Legislator Education
Policymakers, regulators, and legislators at both the federal and state levels play an important role in formulating policy, issuing
guidelines and direction, and passing legislation on issues related to acute and chronic pain management, payment mechanisms,
and the use and regulation of controlled medications. The issue of pain management is complicated, so every decision made,
law passed, or guideline issued has a cascading eect on many aspects of pain management. As such, a deep understanding
of the issues, especially the potential for unintended consequences of these decisions, is essential in formulating eective
comprehensive policy.
GAPS AND RECOMMENDATIONS
GAP 1: Current education for policymakers at the state and federal levels has significant opportunities for improvement for both
acute and chronic pain.
RECOMMENDATION 1A: Strongly encourage education by key and relevant expert stakeholders from the appropriate
professional associations, clinicians, and patient advocacy groups prior to eecting policy on acute and chronic pain.
RECOMMENDATION 1B: Establish criteria for evaluating legislation and regulation based on the principles in the
preamble of this report, ensuring an understanding of all potential unintended consequences of guidelines, policies,
regulations, or legislation that is being considered.
3.4 ACCESS TO PAIN CARE
In the United States, the estimated number of patients with chronic daily pain is 50 million, with 19.6 million having chronic, high-
impact pain.
6
Several factors act as barriers to adequate care, including inadequate insurance coverage for pain management
services,
280
shortages of medical and behavioral pain management specialists,
5
provider underestimation of patients’ reports of
pain,
451
poorly functioning drug supply systems,
452
lack of research on innovative and eective pain management approaches,
28
and — more recently — widespread fear among providers of regulatory scrutiny. The recent advent of retail pharmacies limiting
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63PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
the duration of prescriptions, making unrequested changes to dosages, or placing barriers to obtaining properly prescribed
pain medications has had the unintended consequence of limiting access to optimal pain care. Without such access, many
patients face significant medical complications, prolonged suering, and increased risk of psychiatric conditions.
453
Medical
complications from inadequately treated acute pain may include prolonged recovery time, unanticipated hospital readmissions,
and transition to chronic and persistent pain.
454
Unremitting and inadequately treated pain is also associated with increased
anxiety, depression, disability, unemployment, and lost income.
295
In addition to experiencing medical and psychiatric consequences, individuals who receive inadequate pain treatment may
transition to illicit opioid or other substance misuse. Although the pathway to illicit substance use in pain is not well understood,
a small but growing number of individuals who misuse prescription opioids without the supervision or oversight of a medical
provider transition to using illicit substances, such as heroin, within a year of use.
455
The nonmedical and illicit use of opioids may
increase an individual’s risk for substance use problems, accidental or intentional overdose, or death.
456
Heroin, fentanyl, and
other illicit synthetic opioids continue to drive increasing numbers of overdose deaths.
9
Understanding the indicators associated
with inappropriate opioid use may improve the ability of health care providers to tailor treatments and surveillance without
placing arbitrary limitations on all patients who are prescribed opioids. This understanding could also potentially improve access
to eective care.
There is a concern as to the definition of what an “outlier prescriber” is and to avoid arbitrary limitations without taking into
account the provider expertise and the patient demographic. Careful consideration of how outliers will be defined is needed
to avoid patient harm. Patient care should be based primarily on the clinical context and the patient-clinician interaction. Opioid
stewardship programs can provide a holistic, ecient, comprehensive, multidisciplinary approach to address safer opioid
prescribing within a health system, thus empowering cross-disciplinary collaboration and inclusion with the development of
measures to guide implementation and successful eorts. Quality measures should include function, QOL, and ADL. CMS is
currently implementing sections of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for
Patients and Communities Act (SUPPORT Act). The SUPPORT Act requires CMS to convene a technical expert panel; make
recommendations regarding quality measures for opioids; identify outlier prescribers and furnish technical support regarding
proper prescribing practices; and implement minimum standards for states’ Drug Utilization Review programs regarding opioid
prescribing, including safety edits on refills and daily dosage policies. It is essential to ensure that careful consideration of
clinical context is always considered.
3.4.1 Medication Shortage
Shortages of pharmacologic and biological products, including opioid and non-opioid analgesics, can have severe and
immediate consequences for patient care. Appropriate treatment can be delayed or denied because of unavailability and, in
other cases, result in the use of second-line, less eective alternatives.
457,458
Several underlying factors have contributed to
national shortages, including manufacturing problems that aect the drug supply chain and quality control, as well as regulatory
changes in response to the opioid overdose public health crisis.
452,458
Tracking data from the FDA show that drug shortages
peaked in 2011, with more than 250 new drug shortages, and although the number has steadily declined, 2017 saw 39 new
shortages and a failure to adequately address existing shortages.
458
Health care systems and providers, with clinical pharmacists, are responding to the drug shortages by identifying therapeutic
alternatives and prioritizing supplies. Patient safety events — namely, medication errors — are more likely to occur during times
of shortages because of the increased prescribing of less familiar pharmacologic agents.
452,459
Use of compounded products
or alternative preparations is a common underlying cause of errors.
460
An investigation by the Institute for Safe Medication
Practices into shortage-related patient safety events cited that use of an alternative drug or alternative dosage form/strength
of a substitute drug accounted for up to 27% of reported harmful outcomes.
459,461
Advance notice of shortages, communication
and education, consultation with clinical pharmacists, and standardized management algorithms help mitigate the eects of
drug shortages. For instance, a retrospective chart review of patients admitted to the pediatric intensive care unit during a 2011-
2012 peak shortage of injectable benzodiazepines (e.g., midazolam, lorazepam, diazepam) and fentanyl reported no significant
increase in rates of prescribing error and adverse patient outcomes because of well-established guidelines for prioritized and
alternative analgesic and sedative management protocols.
462
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64 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Current widespread shortages of several key parenteral opioids used for fast and reliable analgesic eects, including morphine,
hydromorphone, and fentanyl, are aecting hospitals and cancer centers nationwide, leading to compromised acute pain
management in the critical care and postoperative settings. Morphine, hydromorphone, and fentanyl are the most commonly
used opioid injectables because of their fast and reliable analgesic eects and because they oer a viable option for patients
unable to tolerate oral administration.
452,457
Other potential analgesic shortages include the NSAIDs ketoprofen and ketorolac
tromethamine, methocarbamol, methadone, promethazine, and remifentanil. In July 2018, the FDA established the Agency
Drug Shortages Task Force, charged with identifying the causes of medication shortages and proposing solutions. The results
will be summarized in a report to Congress, informed by input from the pharmaceutical and health care industries, patient
representatives, the FDA’s federal partners, and Congress.
463
GAPS AND RECOMMENDATIONS
GAP 1: Recurrent shortages in opioid and non-opioid pain medications have created barriers to the proper treatment in patients
with pain.
RECOMMENDATION 1A: The Task Force strongly supports the FDA’s ongoing eorts to monitor, report, and prioritize
the availability of key opioid and non-opioid medications, including injectables such as local anesthetic agents.
RECOMMENDATION 1B: The FDA should make available alternative sources for these medications when critical
shortages are anticipated.
RECOMMENDATION 1C: Support the Agency Drug Shortages Task Force in its endeavors to find solutions to the
critical challenges of drug shortages.
3.4.2 Insurance Coverage for Complex Management Situations
Patients with complex and persistent pain often experience barriers to care related to nonexistent or insucient insurance
coverage and reimbursement for evidence-based medical, behavioral, and complementary pain management services.
Although the HHS National Pain Strategy calls for greater coverage for pain management services, there is a lack of uniformity
in insurance coverage and lack of coverage alignment with current practice guidelines for pain management.
280,464
This is
particularly true for nonpharmacologic
280
and behavioral health interventions.
280,465
The process for determining insurance coverage for pain management services is lengthy and complex, often requiring
product testing, assessment against evidence-based protocols, determination of medical necessity, evidence-based coverage
determination processes, and review by physician networks and stakeholders. Moreover, there is substantial variability in the
availability and structure of guidance regarding the data needed to qualify for coverage provided to developers working on
innovative nonpharmacologic treatments.
280
For example, CMS uses national coverage determinations (NCDs) to determine
whether to cover a particular item or service. In the absence of a national coverage policy, an item or service may be covered
at the discretion of the Medicare contractors based on a local coverage determination. Such practice leads to variation in
coverage of items and services that can aect medical care. In addition, CMS requires testing of products in the Medicare-aged
population for NCDs. Guidance to medication and product developers working on alternatives to opioids and opioid-sparing
technologies; procedures concerning data needed to qualify for CMS coverage determinations; and innovation payments under
CMS programs, especially for Medicare-eligible Americans in pain, is limited to basic statutory language. In contrast, the FDA
provides extensive guidance on data needed to qualify for labeling for products like “abuse deterrent” medicines.
The inconsistencies in insurance policies, the variability in guidance regarding coverage determinations, and the variability
in utilization management tools that coverage providers use can cause delays in service delivery, provision of inadequate
treatment, and added financial and psychosocial burden for patients with pain.
290
Requiring patients and health care
professionals to navigate burdensome and variable coverage policies may contribute to slow development, adoption, and
implementation of timely and eective pain treatments and may force providers to treat patients in a less-than-optimal fashion.
Consistently forcing providers to try a series of non-first-line treatments prior to authorizing treatment plans can be problematic,
hindering appropriate patient care, creating tremendous ineciency, and resulting in a loss of time and resources. This situation
3.4 ACCESS TO PAIN CARE
65PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
is problematic when patients change insurance coverage, requiring a new set of preauthorization rules to be followed and
potentially leading to delays in critical, ongoing treatment.
464
GAPS AND RECOMMENDATIONS
GAP 1: Time and resources are insucient for complex and safe opioid management.
RECOMMENDATION 1A: Reimburse complex opioid and non-opioid management consistent with the time and
resources required for patient education; safe evaluation; risk assessment; reevaluation; and integration of alternative,
non-opioid modalities.
RECOMMENDATION 1B: CMS and private payers should investigate and implement innovative payment models that
recognize and reimburse holistic, integrated, multimodal pain management, including behavioral health.
GAP 2: Many pain-related payer guidelines are outdated with respect to current clinical practice guidelines.
RECOMMENDATION 2A: CMS and private payers should align their reimbursement guidelines for acute and chronic
multidisciplinary pain management with current CPGs.
GAP 3: Payers often do not reimburse for non-opioid pharmacologic therapies that are more expensive than opioids, such as
long-acting local anesthetic injection/infusion and intravenous acetaminophen analgesia.
RECOMMENDATION 3A: CMS and other payers should align their reimbursement guidelines for non-opioid
pharmacologic therapies with current CPGs.
GAP 4: Coordinated, individualized, multidisciplinary care for chronic pain management is a best practice, yet this model of care
is dicult to achieve with current payment models.
RECOMMENDATION 4A: Payers should reimburse pain management using a chronic disease management model.
CMS and private payers should reimburse for integrative, multidisciplinary pain care by using a chronic disease
management model similar to that currently used to reimburse for cardiac rehabilitation and diabetes chronic
care management programs. In addition, reimburse care team leaders for time spent coordinating patient care.
A CPT code should be developed for pain care coordination as well as team and group conferences to enable
multidisciplinary care.
RECOMMENDATION 4B: Payers should reimburse for pain management in a manner that facilitates access in
underserved locations through telehealth or other technology-assisted delivery methods.
3.4.3 Workforce
A 2011 IOM report highlighted the current shortage of pain management specialists, citing that for every physician who is board
certified in pain care, there are more than 28,500 Americans living with chronic pain.
5
As of August 2018, there were 2,300
American Board of Pain Medicine-certified pain specialists
466
and 6,595 physicians certified in pain management by the American
Board of Medical Specialties
467
; many of these physicians have both certifications. Pain management specialists possess expertise
and are specially trained in the evaluation, diagnosis, and treatment of acute and chronic pain.
468
Because of an inadequate
number of specialized pain physicians, PCPs are tasked with managing the majority of patients with painful conditions, often
without adequate time and resources.
469
This indicates the need for an increase in the pain specialist workforce to support PCPs
while also ensuring that specialists and PCPs have adequate time, incentives, and resources to manage patients with painful
conditions. Likewise, access to behavioral pain management is limited because financial incentives are lacking for psychologists
and other providers to specialize in pain. Many insurance programs do not reimburse for behavioral pain treatments, or they
reimburse at a much lower rate than for pharmacologic or interventional treatments. Because of the lack of incentives, not enough
providers are trained in behavioral pain management.
281,284
Taken together, the severe shortage of pain medicine specialists and
under-resourced and insuciently trained PCPs treating pain along with insucient access to behavioral therapists, pharmacists,
and other members of the pain management team has hindered the development of ecient, cost-eective health care delivery
models to treat chronic pain.
5,15,470
3.4 ACCESS TO PAIN CARE
66 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAPS AND RECOMMENDATIONS
GAP 1: There is a shortage of clinicians who specialize in pain. These clinicians include pain physicians, addiction psychiatrists,
psychologists, pharmacists, nurses, NPs, PAs, physical therapists, social workers, and others who make up a
multidisciplinary pain management team. Furthermore, there is a shortage of multidisciplinary pain management teams to
care for patients with complex pain conditions and physical and psychological comorbidities.
RECOMMENDATION 1A: Expand clinician training in acute, chronic, or end-of-life pain evaluation and treatment.
Enhancements should be made in professional school curricula, postgraduate training programs, and continuing
education courses.
RECOMMENDATION 1B: Expand postgraduate (e.g., residency, fellowship) positions to train clinicians as pain
specialists, especially positions that train clinicians to work on multidisciplinary pain management teams.
RECOMMENDATION 1C: Expand the availability of clinician specialists, including physicians, NPs, PAs, nurses,
physical and occupational therapists, psychologists, behavioral health specialists, and social workers.
RECOMMENDATION 1D: Encourage and incentivize the creation of multidisciplinary pain management teams and
programs as centers of excellence, where patients with diverse and complex pain conditions as well as physical and
psychological comorbidities can be managed eectively and investigated for optimal outcomes.
3.4.4 Research
Research is fundamental to advancing both the understanding and treatment of acute and chronic pain. The NIH Help to End
Addiction Long-term (HEAL) initiative is a trans-NIH eort to improve prevention and treatment strategies for opioid misuse and
addiction and to enhance pain management. Resources include governance and guidance as well as research and funding
opportunities. NIH launched the Acute to Chronic Pain Signatures program to investigate the biological characteristics underlying
the transition from acute to chronic pain and to look at mechanisms that make some people susceptible and others resilient
to the development of chronic pain. New knowledge development is needed in various areas of pain research, with emphasis
placed on molecular and cellular mechanisms of pain, the genetics of pain, bio-behavioral pain, and preclinical models of pain.
5,471
Supporting research initiatives throughout these fields across the basic science, translational, and clinical research arenas will
aid in addressing current research gaps. This will lead to understanding the mechanisms of pain and SUD, translating promising
advancements into eective therapies, and identifying best practices to implement in the management of acute and chronic
pain. As novel and proven treatment options emerge to improve acute pain and specific chronic pain conditions, they should be
rapidly incorporated.
GAPS AND RECOMMENDATIONS
GAP 1: Incentives for innovations in the treatment of chronic and acute pain are necessary for the advancement of treatment.
RECOMMENDATION 1A: Support public-private partnerships for improved funding to support and accelerate basic
science, translational, and clinical research of pain and implementation research in health care systems. Allocate
funding to develop innovative therapies and build research capabilities for better clinical outcomes tracking and
evidence gathering.
GAP 2: Sex as a biological variable as well as genetic, epigenetic, and experiential factors in the progression of pain are not
well understood.
RECOMMENDATION 2A: Improve understanding of the specific interplay of sex as a biological variable as well
as genetic and experiential contributions to pain, including identification of biomarkers; factors that play a role in
persistent pain and eventually chronic pain; the role of comorbid conditions; and predictive risk factors.
3.4 ACCESS TO PAIN CARE
67PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
GAP 3: There is a lack of understanding of contributing factors that predispose certain patients to SUD and addiction.
RECOMMENDATION 3A: Further evaluate the lifelong risk factors for the development of SUD rather than the
isolated evaluation of prescription opioid use (e.g., adolescent substance use, early-life trauma).
RECOMMENDATION 3B: Conduct research to identify biomarkers, genetic predisposition, epigenetic mechanisms,
and other patient factors to assist in improved and accurate identification of those patients at risk for SUD.
GAP 4: There is a lack of research on and funding of potentially innovative modes of health care delivery and treatment.
RECOMMENDATION 4A: Increase research into novel strategies that target the underlying mechanisms of chronic
pain, including pharmacologic and biologic research and development; medical devices; medication delivery
systems; neuromodulation; regenerative medicine; and complementary and integrative health approaches, including
movement-based modalities.
RECOMMENDATION 4B: Increase the level of research on accelerating the development and implementation of
integrated pain care.
4
REVIEW OF THE CDC GUIDELINE
69PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
In 2016, in response to growing concerns about overprescribing opioids for pain management and opioid-related overdose,
CDC published a widely read guideline on opioid therapy for chronic pain.
128
Their recommendations focus on the use of opioids
in treating chronic pain in patients 18 years or age or older. The “CDC Guideline for Prescribing Opioids for Chronic Pain” is not
intended for patients who are in active cancer treatment, palliative care, or end-of-life care.
It is important to note that CDC reports that the recent acceleration in deaths from opioid overdose is largely driven by illicit
opioids as opposed to prescribed opioids.
472
Illicit fentanyl has been found in a growing number of toxicology studies of
overdose decedents. Furthermore, given the current state of the overdose crisis, further drastic reduction of clinician prescribing
alone may not have a large eect on decreasing opioid overdose deaths in the short term.
473,474
The CDC Guideline provides useful general guidance for prescribing opioids that is primarily intended for primary care providers.
Various organizations, such as the American College of Physicians, supported the guideline when it was initially released, but
clinicians, patients, professional organizations, and other stakeholders have highlighted important limitations since its publication.
A commentary by Busse et al.
475
identified several limitations related to expert selection, evidence inclusion criteria, method
of evidence quality grading, selective support of some recommendations with low-quality evidence, and instances of vague
recommendations. CDC cited the lack of clinical trials with a duration of one year or longer as lack of evidence for sustained
clinical eectiveness of opioids in chronic pain. The Task Force respectfully points out that there is little clinical trial evidence
showing that opioids lack clinical ecacy for such patients. Furthermore, Tayeb et al.
114
found that lack of long-term ecacy is true
for all common medication and behavioral therapy studies. Long-term studies of therapies for chronic, moderate, or severe pain
are dicult to conduct because of patient drop-out for ineective treatment.
417
One long-term study from VA assessed patients on
opioids versus non-opioid medications over a 12-month study evaluation period.
113
Both groups showed similar changes in pain
severity and pain-related function over 12 months. The authors conclude that the results of this study do not support initiation of
opioid therapy alone for moderate to severe chronic back pain or hip or knee osteoarthritis pain.
113
Noting that the CDC Guideline
focused primarily on patients initiating opioid treatment, Gordon and Connoly
476
discussed application of the guideline to patients
who are already receiving opioid maintenance therapy for chronic pain. Given that chronic pain is associated with many dierent
underlying conditions, with great patient variability in analgesic drug metabolism, risk for abuse, and underlying comorbid medical
condition, further studies are needed to assess the value of long-term opioids alone and in combination with other therapies,
coupled with risk assessment and periodic reevaluation (see Section 3.1: Risk Assessment).
The Task Force recognizes the utility of the 2016 CDC Guideline for many aspects of pain management and its value in
mitigating adverse outcomes of opioid exposure. Unfortunately, misinterpretation, in addition to gaps in the guideline, has led to
unintended adverse consequences. Our report documented widespread misinterpretation of the CDC Guideline — specifically,
the recommendation regarding the 90 morphine milligram equivalents (MME) dose. In November 2018, the American Medical
Association issued a statement advocating against the misapplication of the CDC Guideline.
477
Educating stakeholders about the
intent and optimal application of this guideline and re-emphasis of its core beneficial aspects are essential. Instances have been
reported where the CDC Guideline was misapplied to the palliative care and cancer populations with pain and to providers who
care for these patient populations. It is important to recognize the need for an individualized approach to palliative care and
cancer patients with pain, a population that typically requires higher doses of opioids for pain relief and function, often for long
periods.
306,355
The American Society of Clinical Oncology, the American Society of Hematology, and the National Comprehensive
Cancer Network recently received a key clarification letter from the CDC (February 2019) that the guideline was developed
to provide recommendations for primary care clinicians who prescribe opioids for patients with chronic pain outside of active
cancer treatment, palliative care, and end-of-life care, and the guideline is not intended to deny clinically appropriate opioid
therapy to any patients who suer acute or chronic pain from conditions such as cancer and sickle cell disease.
478
4. REVIEW OF THE CDC GUIDELINE
70 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
The 2016 CDC Guideline, which provided a comprehensive synthesis of scientific evidence on opioid prescribing, was intended
as a tool primarily for PCPs to help inform their decisions about managing pain with opioids and to encourage dialogue and
discussion of risks between providers and patients (shared decision making).
1
Although the CDC Guideline was not intended to
be model legislation, at least 28 states have gone beyond the guidelines and enacted legislation related to opioid prescription
limits. As a result, such unintended consequences have led health care providers to limit or not provide pain treatment due in
part to concerns and undue burdens of investigation and prosecution by drug enforcement.
18
Furthermore, many states and
organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation
to override what should be medical decision making by health care professionals; and have applied them to all physicians,
dentists, NPs, and PAs, including pain specialists.
479–482
Some stakeholders have interpreted the guideline as intended to broadly
reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of
opioids while minimizing the benefit of this medication class when properly managed.
483
A major problematic unintended consequence of the guideline is the forced tapering, medication discontinuation, or
abandonment that many patients with chronic pain on stable long-term doses of opioids have experienced.
484
CDC published
a pivotal article in New England Journal of Medicine on April 24, 2019, specifically reiterating that the CDC Guideline has
been, in some instances, misinterpreted or misapplied. The authors highlight that the dose recommendations in the CDC
Guideline do not address or suggest discontinuation of opioids prescribed at higher dosages. They note “policies invoking
the opioid-prescribing guideline that do not actually reflect its content and nuances can be used to justify actions contrary
to the guideline’s intent.”
1
This conclusion is supported by the comments the Task Force has received indicating that many
patients have experienced access issues related to provider fears and concerns with how the guideline would be interpreted
and have caused some to consider obtaining opioids from illicit sources or suicide (see Section 3.2: Stigma). The FDA recently
issued a safety announcement recognizing harm reported from sudden discontinuation of opioid pain medicines, including
serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide. They are requiring label changes to
guide prescribers on gradual, individualized tapering.
485
PCPs should be encouraged to refer to or seek input from pain
specialists and (potentially) addiction specialists in complex or high-risk patient scenarios (see Section 2.5: Behavioral Health
Approaches). In the expert opinion of the Task Force members, the CDC Guideline does not suciently emphasize that optimal
pain management begins with identification of the cause of the pain and the biopsychosocial mechanisms that contribute to
its severity and associated disability. (Please also refer to other sections of this report for further discussion and information
on various modalities for the treatment of pain, including Section 2.2: Medications, Section 2.3: Restorative Therapies, Section
2.4: Interventional Procedures, Section 2.5: Behavioral Health Approaches, and Section 2.6: Complementary and Integrative
Health.)
486
The CDC Guideline recommends that opioids prescribed for acute pain be limited to three or fewer days and that more than
a seven-day supply is rarely necessary.
128
Various health insurance plans, retail pharmacies, and local and state governments
are implementing the CDC Guideline as policy, limiting the number of days a patient can receive prescription opioids even
when the seriousness of the injury or surgery may require opioids for adequate pain management for a longer period. A more
even-handed approach would balance addressing opioid overuse with the need to protect the patient-provider relationship
by preserving access to medically necessary drug regimens and reducing the potential for unintended consequences.
487
The vast majority of medical organizations, in response to the 90-day public comment period to the Task Force draft report,
supported this balanced approach. Policies should help ensure safe prescribing practices, minimize workflow disruption, and
ensure that beneficiaries have access to their medications in a timely manner, without additional, cumbersome documentation
requirements.
487
In essence, clinicians should be able to use their clinical judgement to determine opioid duration for their
patients while considering risk assessment recommendations as discussed in Section 3.1: Risk Assessment. Safe opioid
stewardship involves a proper history and examination, periodic reevaluation, and risk assessment, with a focus on measurable
outcomes, including function, QOL, and ADLs.
Recommendations noted in this section are organized into two groups:
UPDATE: Requires updated scientific evidence since the release of the CDC Guideline in March 2016.
EMPHASIZE OR EXPAND: Refers to content already in the CDC Guideline or areas to expand on.
4. REVIEW OF THE CDC GUIDELINE
71PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
UPDATE
1: There is an absence of high-quality data on the duration of opioid eectiveness for chronic pain, which has been interpreted
as a lack of benefit.
RECOMMENDATION 1A: Support studies to determine the long-term ecacy of opioids in the treatment of
chronic pain syndromes (primary and secondary) in dierent populations as determined by clinical context, clinical
conditions, and comorbidities.
RECOMMENDATION 1B: Conduct clinical trials on specific disease entities, with a focus on patient variability and
response to tissue injury and on the eectiveness of opioid analgesics. Design trials to be applicable in real-world
settings (e.g., patients receiving trialed opioid medications while maintaining the usual multimodal therapy).
2: There is an absence of criteria for identifying the sub-population of patients for whom opioids may contribute significantly to
improve their pain management and therefore their QOL and functionality.
RECOMMENDATION 2: Conduct clinical studies or complete systematic reviews to identify which chronic pain
conditions and patient characteristics are appropriate for long-term opioid treatment in conjunction with the various
non-opioid modalities.
EMPHASIZE OR EXPAND
3: There is wide variation in patient and disease factors that determine the dose of opioids that is optimal for pain relief and
minimizes risk.
RECOMMENDATION 3A: Consider patient variables that may aect opioid dose in patients prior to initiation of
opioid therapy, including respiratory compromise, individual patient metabolic variables, or dierences between
opioid medications that could aect plasma opioid concentrations.
RECOMMENDATION 3B: Perform comprehensive initial assessments for patient management, with an
understanding of the need for periodic comprehensive reevaluation to adjust the medication dose.
RECOMMENDATION 3C: Careful consideration should be given to patients on an opioid pain regimen who have
additional risk factors for OUD (see Section 3.1: Risk Assessment).
RECOMMENDATION 3D: The CDC Guideline, meant for primary care clinicians, should explicitly reemphasize that
the 90 MME/day maximum dose recommendation is not mandatory but is a target that may be exceeded if clinically
appropriate when benefits outweigh risks.
4: Specific guidelines addressing opioid tapering and escalation need further elucidation.
RECOMMENDATION 4A: Undertake opioid tapering or escalation only after a thorough assessment of the risk-
benefit ratio. This assessment should be conducted in collaboration with the patient.
RECOMMENDATION 4B: Develop guidelines for tapering and dose escalation for the sub-populations of patients
who have chronic pain conditions that includes consideration of their comorbidities.
RECOMMENDATION 4C: Consider maintaining therapy for patients who are stable on long-term opioid therapy and
for whom the benefits outweigh the risks.
5: Multiple potential causes of worsening pain are often not recognized or considered. Nontolerance-related factors include
iatrogenic causes such as surgery, flares of the underlying disease or injury, and increased ergonomic demands or
emotional distress.
RECOMMENDATION 5A: When a stable dose has been established for at least two months, avoid increases in the
dose until the patient has been reevaluated for the underlying causes of elevated pain or possible OUD risk.
4. REVIEW OF THE CDC GUIDELINE
72 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
RECOMMENDATION 5B: Considerations to avoid dose escalation should include opioid rotation, non-opioid
medications, interventional strategies, cognitive behavioral strategies, complementary and integrative health
approaches, and PT.
6: Although the risk of overdose by benzodiazepine co-prescription with opioids is well established, this combination may
still have clinical value in patients who have chronic pain and comorbid anxiety, which commonly accompanies pain, and
in patients who have chronic pain and spasticity. However, initiating regular long-term use of benzodiazepines with opioids
should be done with caution, because SSRIs, SNRIS, and psychotherapies are preferred treatments for anxiety disorders.
(See Section 2.2: Medications for further discussion about anxiolytics as well as treatment of anxiety and chronic pain.)
RECOMMENDATION 6A: If clinically indicated, co-prescription should be managed and coordinated by physicians
and clinician specialists who have knowledge, training, and experience in co-prescribing benzodiazepines with
opioids. For those patients who have anxiety disorders or SUD who have been prescribed benzodiazepines, risk
mitigation strategies and counseling, collaboration with experts in mental health, and the use of psychological
modalities should be considered.
RECOMMENDATION 6B: Develop CPGs that focus on tapering for co-prescription of benzodiazepines and opioids.
7: The variability in eectiveness and safety (respiratory depression and abuse liability) at any given dose of an opioid is not
clearly defined and may vary between dierent opioids and dierent patients. Consequently, the risk-benefit balance for
opioid management of pain may vary for individual patients. Similarly, the balance of benefit and risk for doses above 90
MME/day may be acceptable in some patients. Failure to closely monitor patients when opioid dose is adjusted puts them at
risk for either inadequate pain control or overdose toxicity.
RECOMMENDATION 7A: Use the lowest eective opioid dose and shortest duration appropriate for the pain
condition that balances benefits, risks, and adverse reactions. Clinicians should individualize dose based on a
carefully monitored medication trial. With each dose adjustment patients should be assessed at expected peak drug
concentration for analgesic eectiveness and adverse eects, such as respiratory compromise and sedation.
RECOMMENDATION 7B: Additional factors influence risk and benefit that should be considered; therefore,
guidance regarding dose should not be applied as strict limits. Providers should use established and measurable
goals such as functionality, ADLs, and QOL measures.
8: The duration of pain following an acute, severely painful event such as trauma, surgery, or burn is widely variable. For clarity,
the CDC Guideline recommendation #6 refers to acute pain that is non-surgical, non-traumatic pain.
RECOMMENDATION 8A: Appropriate duration of therapy is best considered within guidelines, and then ultimately
determined by the treating clinician. The CDC recommendation for duration of treatment should be emphasized as
guidance only for a general approach, with individualized patient care as the primary goal, and the clinician then
considering all modalities for best outcomes.
RECOMMENDATION 8B: Develop and/or update acute pain management guidelines for common surgical
procedures and trauma management, as noted in Section 2.1.1: Acute and Chronic Pain, Recommendation 2a.
RECOMMENDATION 8C: To address this variability and provide an easy solution to the challenges of medication
duration, consideration should be given to a partial refill system.
FEDERAL RESOURCES CENTER
73PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
FOR PATIENTS AND FAMILIES
Pain Management Fact Sheet
Information about past, present, and future of pain management.
https://report.nih.gov/NIHfactsheets/Pdfs/PainManagement(NINR).pdf
VHA Pain Management Website
Information for Veterans and the public, including an online course.
https://www.va.gov/PAINMANAGEMENT/Veteran_Public/index.asp
Behavioral Health Treatment Services Locator
A confidential and anonymous source of information for those seeking treatment facilities in the United States or U.S. territories
for substance abuse/addiction or mental health conditions.
https://findtreatment.samhsa.gov/
Medicare Coverage
Medicare oers medically necessary benefits, including transitional care management, chronic care management and complex
chronic care management, behavioral health integration and collaborative care management, PT and OT, in- and outpatient pain
rehabilitation, and electrical nerve stimulation. Local coverage may include additional options.
https://www.medicare.gov/what-medicare-covers
CDC Information for Patients
Resources for patients, including responses to frequently asked questions about opioids for chronic pain and other
helpful materials.
https://www.cdc.gov/drugoverdose/patients/index.html
Tribal Consultation Services
The Health Resources & Services Administration’s (HRSA’s) Oce of Regional Operations regularly attends, presents,
and provides consultation as needed or requested to help tribes and nations use HRSA programs to address SUD/OUD in
their communities.
https://www.hrsa.gov/about/organization/bureaus/ohe/populations/aian.html
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
This CPG’s patient summary provides an overview of chronic pain, treatment, and questions patients may have about
opioid medications.
https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPGPatientSummary022717.pdf
ClinicalTrials.gov
This site is a database of privately and publicly funded clinical studies conducted around the world.
https://clinicaltrials.gov/
What to Ask Your Doctor Before Taking Opioids
The FDA provides this list of questions patients can ask their health care provider before getting a prescription for an
opioid medication.
https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm529517.htm
FEDERAL RESOURCES CENTER
74 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Prescription Opioids: What You Need to Know
This CDC fact sheet describes the risks and side eects associated with opioid use.
https://www.cdc.gov/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf
Safe and Responsible Use of Opioids for Chronic Pain: A Patient Information Guide
This VA-issued patient guide provides information about opioid safety and alternatives to opioid therapy.
https://www.va.gov/PAINMANAGEMENT/Opioid_Safety/OSI_docs/10-791-Safe_and_Responsible_Use_508.pdf
DEA National Prescription Drug Take Back Day
DEA’s biannual event at multiple national locations provides a safe, convenient, and anonymous means of disposing of
prescription drugs. Federal Drug Take Back Day is held at federal buildings typically on Wednesdays prior to public Drug Take
Back Day events.
https://takebackday.dea.gov/
National Prescription Drug Take Back Day
This Google-based resource includes take-back facility locator, fact sheets, and frequently asked questions.
https://get.google.com/rxtakeback/
Opioid Treatment Program Directory
SAMHSA’s online directory of opioid treatment programs is cataloged by state.
https://dpt2.samhsa.gov/treatment/directory.aspx
Buprenorphine Practitioner Locator
SAMHSA maintains an online list of practitioners authorized to treat opioid dependency with buprenorphine, cataloged by state.
https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator
National Suicide Prevention Lifeline
This site provides 24/7, free, confidential support for people in distress as well as prevention and crisis resources.
https://suicidepreventionlifeline.org/
Poison Help
Nationwide poison control centers provide educational services to prevent poisonings as well as help during poison
emergencies to people who need it.
https://poisonhelp.hrsa.gov/
Poison Help telephone number: 1-800-222-1222
Disposal of Unused Medicines: What You Should Know
The FDA maintains a list of medicines that can be disposed of by flushing when take-back options are not readily available.
https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/
safedisposalofmedicines/ucm186187.htm
Help, Resources and Information: National Opioids Crisis
HHS maintains an online catalog of resources categorized by prevention, treatment, recovery, and general information about
the opioid crisis.
https://www.hhs.gov/opioids/
National Helpline: 1-800-662-4357
Opioid Overdose Prevention Toolkit
SAMHSA’s “Opioid Overdose Prevention Toolkit” provides strategies to help prevent opioid-related overdoses and deaths.
https://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA18-4742
FEDERAL RESOURCES CENTER
75PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
National Capital Region Pain Initiative
The National Capital Region Pain Initiative improves access to care for Tricare beneficiaries with pain, TBI, and PTSD across the
National Capital Region. A key component is education; including sta, providers, patients, and families. These enhancements
to our existing pain programs ensure a coordinated eort across the National Capital Region
https://www.capmed.mil/CapMedServices/NCRPI/SitePages/Home.aspx
Nursing Home Compare
CMS monitors the quality of care in the nation’s long-term care facilities (nursing homes), requiring that residents receive
necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being,
including recognition and management of pain.
https://www.medicare.gov/nursinghomecompare/search.html
FOR PROVIDERS
Implementation Guide. Factors to Consider in Managing Chronic Pain: A Pain Management Summary
This resource for integrating with an EHR system helps health care providers see all EHR data before making decisions about
pain management in one screen to support individualized treatment.
https://cds.ahrq.gov/sites/default/files/cds/artifact/476/ImplementationGuidePainManagementSummary50810012018.pdf
CDC Interactive Training Series
These online training modules help health care providers apply CDC’s recommendations in the clinical setting through patient
scenarios, videos, knowledge checks, tips, and resources.
https://www.cdc.gov/drugoverdose/training/online-training.html
Six Building Blocks
This Web-based training guide for clinicians, health care sta, quality improvement personnel, practice coaches, and clinic
administrators focuses on improving patient care through chronic opioid therapy.
https://www.ahrq.gov/professionals/prevention-chronic-care/improve/six-building-blocks.html
Management of Suspected Opioid Overdose with Naloxone by Emergency Medical Services Personnel
This systematic review supports the development of an evidence-based guideline for naloxone use.
https://eectivehealthcare.ahrq.gov/topics/emt-naloxon/systematic-review
Technology Transfer Centers Program
SAMHSA’s organization of technology transfer centers (TTCs) focuses on helping health care providers and organizations
incorporate eective practices into SUD treatment, mental health treatment, and recovery services. The TTC program includes
Addiction TTCs, Mental Health TTCs, and Prevention TTCs.
https://www.samhsa.gov/technology-transfer-centers-ttc
Evidence-Based Practices Resource Center
This collection of EBP resources includes Treatment Improvement Protocols, toolkits, resource guides, CPGs, and other
science-based resources focused on improving prevention, treatment, and recovery support services for mental health
conditions and SUD.
https://www.samhsa.gov/ebp-resource-center
Providers Clinical Support System
SAMHSA created this online curriculum to train health care providers on evidence-based approaches to opioid abuse and other
SUDs in screening, assessment, treatment recovery services, and related public health issues.
https://pcssnow.org/
FEDERAL RESOURCES CENTER
76 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
Opioid Analgesic Risk Evaluation and Mitigation Strategy
This education blueprint is for health care providers involved in the treatment and monitoring of patients with pain.
https://www.accessdata.fda.gov/drugsatfda_docs/rems/Opioid_analgesic_2018_09_18_FDA_Blueprint.pdf
HRSA Bureau of Health Workforce Website
HRSA’s Bureau of Health Workforce supports pain management training for postdoctoral students, nurse anesthetist trainees,
and medical residents.
https://www.hrsa.gov/about/organization/bureaus/bhw/index.html
SAMSHA SAFE-T Risk Card
The downloadable Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals (SAFE-T) card describes
a five-step evaluation and triage process for suicide assessment.
https://www.integration.samhsa.gov/images/res/SAFE_T.pdf
VA/DoD Clinical Practice Guideline Suicide Prevention Pocket Guide
This pocket guide provides a summary of clinical practice algorithms and tables from the VA/DoD Clinical Practice Assessment
and Management of Patients at Risk for Suicide.
https://www.healthquality.va.gov/guidelines/MH/srb/VASuicidePreventionPocketGuidePRINT508FINAL.pdf
VA/DoD Clinical Practice Guidelines: Management of Opioid Therapy for Chronic Pain
This VA/DoD CPG providing evidence-based recommendations for the management of opioid therapy for chronic pain conditions.
https://www.healthquality.va.gov/guidelines/Pain/cot/
National Institute on Drug Abuse: Medications to Treat Opioid Use Disorder
This report provides research-informed responses to questions concerning the treatment of OUD.
https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-addiction/overview
HRSA Opioid Crisis Webpage
This resource page provides information about technical assistance and training for the prevention and treatment of OUD.
https://www.hrsa.gov/opioids
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
CDC provides comprehensive recommendations for PCPs prescribing opioids for chronic pain.
https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Additional HHS Resources
CDC provides a list of HHS resources, with links to HHS reports and tools.
https://www.cdc.gov/drugoverdose/resources/hhs.html
SAMHSA Treatment Improvement Protocol 63: Medications for Opioid Use Disorder
This site discusses the use of methadone, naltrexone, and buprenorphine to treat OUD as well as other strategies and services
necessary to support recovery for individuals with OUD.
https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-
and-Parts-1-5-/SMA18-5063FULLDOC
MATx Mobile App to Support Medication-Assisted Treatment of Opioid Use Disorder
SAMHSA’s mobile app supports clinicians who provide medication-assisted treatment for OUD.
https://store.samhsa.gov/apps/mat
Integration of Buprenorphine into HIV Primary Care Settings
Training and implementation tools assist in the treatment of SUD in primary care settings.
https://targethiv.org/ihip/buprenorphine
FEDERAL RESOURCES CENTER
77PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
CMS Roadmap: Fighting the Opioid Crisis
This road map describes the key areas of focus and the way forward for addressing the opioid crisis.
https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Opioid-epidemic-roadmap.pdf
CMS Regional Oces
CMS’ regional oces play a leading role in health care provider education, including through the chief medical ocer’s sta.
https://www.cms.gov/about-cms/agency-information/regionaloces/index.html
FOR RESEARCHERS
NIH Helping to End Addiction Long-term (HEAL) Initiative
Part of a trans-NIH eort to improve prevention and treatment strategies for opioid misuse and addiction and to enhance pain
management, this site’s resources include governance and guidance as well as funding opportunities.
https://www.nih.gov/research-training/medical-research-initiatives/heal-initiative
HHS 5-Point Strategy to Combat the Opioid Crisis
This site outlines HHS’ comprehensive five-point strategy to address the national opioid crisis.
https://www.hhs.gov/opioids/about-the-epidemic/hhs-response/index.html
CMS Opioid Prescribing Mapping Tool
This interactive mapping tool shows geographic comparisons of de-identified prescriptions filled in the United States.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/
OpioidMap.html
HEAL Partnership Committee
This committee subgroup of the HEAL Multi-Disciplinary Working Group formed to help guide HEAL program eorts to address
pain and addiction.
http://www.nih.gov/heal-initiative/heal-partnership-committee
ACRONYMS
79PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
ACT Acceptance and Commitment Therapy
ADF Abuse-Deterrent Formulation
ADL Activities of Daily Living
AHRQ Agency for Healthcare Research and Quality
BT Behavioral Therapy
CARA Comprehensive Addiction and Recovery Act
CBP Clinical Best Practice
CBT Cognitive Behavioral Therapy
CDC Centers for Disease Control and Prevention
CDC Guideline CDC Guideline for Prescribing Opioids for Chronic Pain
CME Continuing Medical Education
CMS Centers for Medicare & Medicaid Services
COX Cyclooxygenase
CPG Clinical Practice Guideline
CPT Current Procedural Terminology
CRPS Complex Regional Pain Syndrome
DEA U.S. Drug Enforcement Administration
DoD U.S. Department of Defense
EAET Emotional Awareness and Expression Therapy
EBP Evidence-based Practice
ECHO Extension for Community Healthcare Outcomes
ED Emergency Department
EHR Electronic Health Record
ERAS Enhanced Recovery After Surgery
ESI Epidural Steroid Injection
FDA U.S. Food and Drug Administration
GI Gastrointestinal
HEAL Helping to End Addiction Long-term
HHS U.S. Department of Health and Human Services
HRSA Health Resources & Services Administration
IHS Indian Health Service
ACRONYMS
80 PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
IOM Institute of Medicine
MBSR Mindfulness-based Stress Reduction
MHS Military Health System
MME Morphine Milligram Equivalent
MS Multiple Sclerosis
NCD National Coverage Determination
NEJM The New England Journal of Medicine
NIH National Institutes of Health
NP Nurse Practitioner
NSAID Nonsteroidal Anti-inflammatory Drug
OB-GYN Obstetrician/Gynecologist
OT Occupational Therapy
OUD Opioid Use Disorder
PA Physician Assistant
PBM Pharmacy Benefit Manager
PCP Primary Care Provider
PDMP Prescription Drug Monitoring Program
PNB Peripheral Nerve Block
PRF Pulse Radio-Frequency Lesioning
PSH Perioperative Surgical Home
PT Physical Therapy
PTSD Post-traumatic Stress Disorder
QOL Quality of Life
RCT Randomized Controlled Trial
RF Radio Frequency
SAFE-T Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals
SAMHSA Substance Abuse and Mental health Services Administration
SCD Sickle Cell Disease
SNB Sympathetic Nerve Block
SNRI Serotonin-Norepinephrine Reuptake Inhibitor
SSRI Selective Serotonin Reuptake Inhibitor
SUD Substance Use Disorder
SUPPORT Act Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and
Communities Act
Task Force Pain Management Best Practices Inter-Agency Task Force
TBI Traumatic Brain Injury
TCA Tricyclic Antidepressant
ACRONYMS
81PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
TENS Transcutaneous Electrical Nerve Stimulation
TTC Technology Transfer Center
TU Therapeutic Ultrasound
UDT Urine Drug Test
VA U.S. Department of Veterans Aairs
VHA Veterans Health Administration
WHO World Health Organization
REFERENCES
REFERENCES
83PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT
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2. National Institute on Drug Abuse. Drugs, Brains, and
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science-addiction/preface. Published 2018.
3. National Institute on Drug Abuse. Misuse of Prescription
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4. American Society of Addiction Medicine. Public Policy
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National Academies of Sciences, Engineering, and
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9. Ahmad F, Rossen L, Spencer M, Warner M, Sutton
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Center for Health Statistics. https://www.cdc.gov/nchs/
nvss/vsrr/drug-overdose-data.htm. Published 2018.
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guidelines for the treatment of acute pain and cancer
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JAMA. 1995;274(23):1874-1880.
11. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM,
Ganzini L. Measuring pain as the 5th vital sign does not
improve quality of pain management. J Gen Intern Med.
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12. Borg H. Electronic health records: agenda-based
medicine. J Am Physicians Surg. 2017;22(2):48-54.
13. Huntoon L. The Disaster of Electronic Health Records. J
Am Physicians Surg. 2016;21(2):35-37.
14. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship
Between Clerical Burden and Characteristics of
the Electronic Environment With Physician Burnout
and Professional Satisfaction. Mayo Clin Proc.
2016;91(7):836-848. doi:10.1016/j.mayocp.2016.05.007
15. Lippe PM, Brock C, David J, Crossno R, Gitlow S. The
First National Pain Medicine Summit--final summary
report. Pain Med Malden Mass. 2010;11(10):1447-1468.
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16. Guy GP, Zhang K, Bohm MK, et al. Vital Signs: Changes
in Opioid Prescribing in the United States, 2006–2015.
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EXECUTIVE SUMMARY
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EXECUTIVE SUMMARY
PAIN MANAGEMENT BEST PRACTICES INTERAGENCY TASK FORCE REPORT