Opinion

Combating the Opioid Overdose Crisis and Alleviating Chronic Pain

By Cheryl Larson & Adam Seidner
December 13, 2019 at 5:00 am ET

With more than 47,600 Americans dying from opioid overdoses in 2017 alone, our nation’s opioid crisis is devastating people, families and communities across the country. 

As efforts to combat this national crisis continue, we must not overlook that the roots of the opioid overdose epidemic lie in inadequately managed pain — especially chronic pain. Today, 50 million Americans suffer from chronic pain, nearly half of whom are living with pain that significantly impairs their ability to go about their daily lives. This includes millions of people who are still employed and trying to manage their symptoms. 

Chronic pain negatively affects a person’s quality of life and has also been shown to impact social environments and mental health. Patients need access to safe and effective treatments to manage their pain, and opioids should not be a first-line treatment option.

Everyone experiences pain differently, and there are many challenges to assessing, diagnosing and managing it. Over the past decade, the number of pain management-related studies, policies and guidelines that were proposed and adopted increased by hundreds compared to the prior years. 

The influx of pain management guidelines and regulations — state and federal, public and private — in response to the opioid misuse and overdose epidemic has impacted the care available to those in need of acute and chronic pain management. In general, policies have good intentions but can have unintended consequences and cause confusion with conflicting recommendations. One example of this can be seen by reading the Centers for Disease Control and Prevention’s April 2019 commentary in The New England Journal of Medicine regarding its own “Guideline for Prescribing Opioids for Chronic Pain” (2016), stating many resulting policies and practices are inconsistent with the intent in its recommendation.

While these efforts have resulted in lower opioid prescribing rates, they do not address the underlying problem of ineffective treatment or untreated pain. They have, in fact, left millions of patients who were being poorly managed with chronic opioids little recourse for effective pain treatment. 

In the absence of meaningful access to a coordinated and comprehensive approach to non-opioid therapies as part of the full toolbox of pain treatment options, there is rising concern that these efforts are limiting access to interdisciplinary, multimodal, integrative pain management. There is growing consensus that we need to provide a cost-efficient yet comprehensive and individualized approach to care that includes all necessary evidence-based treatments and self-care for the patient, if we are to succeed in treating pain in ways that do not exacerbate the opioid crisis.  

One of the key policy agreements needed to combat this crisis is a consensus on how to define or measure effective pain care — especially its impact on overall function, sleep, mood, stress and activity.  More clarity is required about the prevention, causes and mechanisms of chronic pain, and what outcomes define successful treatment. 

The federal research investment to study pain and outcomes is clearly not commensurate with its burden on society. Additional research is needed for us to understand what combination of pharmacologic and nonpharmacologic treatments work best and how those treatments impact outcomes over time.

There is wide agreement that a person-centered and coordinated approach to pain management is the best kind of care. This includes a range of evidence-based, comprehensive treatment options such as physical therapy, acupuncture, cognitive behavioral therapy, nerve block injections, massage therapy, or chiropractic and osteopathic manipulation. Shifting the treatment approach from one that relies heavily on a compartmentalized view of the patient in pain to an individualized solution will result in better outcomes for people living with pain. 

An example of systematic improvement recognizes that traditional health care fee-for-service payment models reimburse for the service performed. A next step in these models is pay-for-coordination, which involves payment for specified care coordination services, usually between certain types of providers. Coordinating care between providers can help create a single treatment plan and help reduce redundant testing and treatments and would align outcome expectations. 

Further, in value-driven care models of health services, physicians, hospitals and other health care providers could be reimbursed on measures including quality, efficiency, cost, functional outcomes and patient experience. A value-driven care model aligns and maximizes cost efficiency with function and clinical outcomes. 

Currently, health plans and self-insured employers are seeking ways to improve health care outcomes through comprehensive management programs. Pain management should be included in those comprehensive programs.   

These shifts across the health care sector are promising but currently siloed. That’s why stakeholders from more than 75 leading organizations, including the Midwest Business Group on Health and The Hartford, have come together to form the Alliance to Advance Comprehensive Integrative Pain Management

The alliance is a multi-stakeholder collaborative, comprised of people living with pain, patient and caregiver advocates, public and private insurers, government agencies, researchers, purchasers of health care, policy experts, and a full spectrum of health care professionals involved in the delivery of comprehensive integrative pain management. In advocating for policies that increase CIPM education for health care professionals, the public, and people with pain, the alliance’s goal is for health care professionals to confidently and knowledgeably manage pain by addressing the individual’s total health and well-being.

We commend the progress that has been made so far to address the opioid crisis. However, we must continue to improve access to CIPM. This is a complex problem with myriad causes. 

Just saying “no” to opioid prescribing does not solve the problem. Instead, working collaboratively across the health care ecosystem to increase access to CIPM will move us in the right direction.

 

Cheryl Larson is president and CEO of Midwest Business Group on Health. Adam Seidner, MD, MPH, is chief medical officer of The Hartford.

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