Draft Report Overview

The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health. This draft report describes preliminary recommendations of the Task Force that will be finalized and submitted to Congress in 2019, following a 90-day public comment period. Initial key concepts:

Balanced pain management should be based on a biopsychosocial model of care.

pain management should be based on a biopsychosocial model of care. Individualized, patient-centered care is vital to addressing the public health pain crisis.

patient-centered care is vital to addressing the public health pain crisis. Ensure better and safer opioid stewardship through risk assessment based on patients’ medical, social, and family history to ensure safe and appropriate prescribing.

stewardship through based on patients’ medical, social, and family history to ensure safe and appropriate prescribing. Multidisciplinary approach to chronic pain that focuses on the patient’s medical condition, co-morbidities, and various aspects of care including: Medications. Different classes depending on patient medical conditions and history. Restorative movement therapies. Physical and occupational therapy, massage therapy, aqua therapy. Interventional procedures. Different types of minimally invasive procedures can be important for both acute and chronic pain. Complementary and integrative health. Acupuncture, yoga, tai chi, meditation. Behavioral health/psychological interventions. Coping skills, cognitive behavioral therapy.

approach to chronic pain that focuses on the patient’s medical condition, co-morbidities, and various aspects of care including: Multi-modal approach to acute pain in the surgical, injury, burn and trauma setting.

to acute pain in the surgical, injury, burn and trauma setting. Perioperative surgical home and acute pain guidelines to provide a framework for improved patient experience and outcomes.

to provide a framework for improved patient experience and outcomes. Addressing drug shortages that might affect acute and chronic pain care.

that might affect acute and chronic pain care. Access to care is vital through improved health care coverage for various treatment modalities and an enlarged workforce of pain specialists and behavioral health clinicians to help guide and support appropriately trained primary care clinicians.

is vital through improved health care coverage for various treatment modalities and an enlarged workforce of pain specialists and behavioral health clinicians to help guide and support appropriately trained primary care clinicians. Stigma is a major barrier to treatment, so it is important to provide empathy and a non-judgmental approach to improve treatment and outcomes.

is a major barrier to treatment, so it is important to provide empathy and a non-judgmental approach to improve treatment and outcomes. Education through societal awareness, provider education and training, and patient education are needed to understand choices and promote therapeutic alliances between patients and providers.

through societal awareness, provider education and training, and patient education are needed to understand choices and promote therapeutic alliances between patients and providers. Innovative solutions to pain management such as telemedicine, tele-mentoring, mobile apps for behavioral and psychological skills, newer medicines, and medical devices should be utilized as part of the overall approach to pain management.

solutions to pain management such as telemedicine, tele-mentoring, mobile apps for behavioral and psychological skills, newer medicines, and medical devices should be utilized as part of the overall approach to pain management. Research is required to develop a better understanding of the mechanisms of pain, preventive measures, the use of innovative medical devices and medications to prevent the acute-to-chronic pain transition, and methods to improve outcomes of chronic pain conditions.

is required to develop a better understanding of the mechanisms of pain, preventive measures, the use of innovative medical devices and medications to prevent the acute-to-chronic pain transition, and methods to improve outcomes of chronic pain conditions. Special populations are highlighted, including pediatric, women, older adults, American Indians/Alaskan Natives, active duty soldiers/veterans, sickle cell disease (as an example of a chronic relapsing condition).

Sections:

1. Introduction

2. Clinical Best Practices

2.1 Approaches to Pain Management

2.1.1 Acute Pain

2.2 Medication

2.2.1 Risk Assessment

2.2.2 Overdose Prevention Education and Naloxone

2.3 Restorative Therapies

2.4 Interventional Procedures

2.4.1 Perioperative Management of Chronic Pain Patients

2.5 Behavioral Health Approaches

2.5.1 Access to Psychological Interventions

2.5.2 Chronic Pain Patients With Mental Health and Substance Use Comorbidities

2.6 Complementary and Integrative Health

2.7 Special Populations

2.7.1 Unique Issues Related to Pediatric Pain Management

2.7.2 Older Adults

2.7.3 Unique Issues Related to Pain Management in Women

2.7.4 Pregnancy

2.7.5 Chronic Relapsing Pain Conditions

2.7.6 Sickle Cell Disease

2.7.7 Health Disparities in Racial and Ethnic Populations, Including African-Americans, Latinos, American Indians, and Alaska Natives

2.7.8 Military Personnel and Veterans

3. Cross-Cutting Clinical and Policy Best Practices

3.1 Stigma

3.2 Education

3.2.1 Public Education

3.2.2 Patient Education

3.2.3 Provider Education

3.3 Access to Pain Care

3.3.1 Medication Shortage

3.3.2 Insurance Coverage for Complex Management Situations

3.3.3 Workforce

3.3.4 Research

4. Review of the CDC Guideline

Acronyms

References

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1. Introduction

The experience of pain has been recognized as a national public health problem with profound physical, emotional, and societal costs.1 Today, chronic pain affects an estimated 50 million U.S. adults, and as many as 19.6 million of those adults experience high-impact chronic pain that interferes with daily life or work activities.2 Pain management stakeholders have been working to improve care for those suffering from acute and chronic pain in an era challenged by the opioid crisis.3

At the same time, our nation is facing an opioid crisis that has seen an unprecedented rise of overdose deaths associated with prescription opioids, heroin, and synthetic opioids in the past two decades.4 The practice of pain management and the opioid crisis have influenced one another as they each have evolved in response to different influences and pressures. It is imperative to strike a balance between ensuring that patients with painful conditions can work with their health care providers to develop an integrative pain treatment plan that optimizes function, quality of life (QoL), and productivity while also ending the devastating effects of opioid misuse.

“The ongoing opioid crisis lies at the intersection of two substantial public health challenges — reducing the burden of suffering 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). The practice of pain management began to undergo significant changes in the 1990s, when pain experts recognized that inadequate assessment and treatment of pain became a public health issue.1 Recommendations for improving the quality of pain care5 were followed by initiatives that recognized patients’ reported pain scores as “The 5th Vital Sign.”6 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) common across all medical disciplines and settings led to a lack of sufficient time for health care professionals to spend with patients to conduct assessment of pain and determine optimal treatment plans. The administrative burden of using the EHR contributes significantly to physician burnout, likely affecting their capacity to manage the complexity of pain care.7,8,9 As the mandate for improved pain management has increased, there was and remains a need for greater education and greater time and resources to respond to the greater needs of patients with painful conditions.3,10

The emergence of standards recommending the improvement of pain scores, and greater use of opioids, along with aggressive marketing of new opioid formulations, in addition to limited time and resources, and limited coverage for non-opioid therapies, there resulted a liberalization of opioid prescribing.3,11 Prescription opioids can be used to treat acute and chronic pain and are often prescribed following surgery or injury as well as for a subset of patients with medical conditions such as complex cancer or inflammatory, neurological, and musculoskeletal conditions. However, multidisciplinary, multimodal approaches to acute and chronic pain are often not supported in time and resources, leaving clinicians with few options to treat often challenging and complex underlying conditions. 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 opioid epidemic, including the U.S. Department of Health & Human Services (HHS) 5-Point Strategy to Combat the Opioid Crisis.12 In addition, there are various efforts 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.

The significant public awareness and the pressure for both federal and state regulatory agencies and other stakeholders to address the opioid crisis has in part contributed to health care providers limiting the number of opioid prescriptions they write. Regulatory oversight has also led to fears of prescribing among some clinicians, with some refusing to prescribe opioids even to established patients on a stable opioid regimen.13 This increased vigilance and targeting of the misuse of prescription opioids and the tightening of their availability have in some situations led to unintended consequences, such as patient abandonment and forced tapering, with established patients with pain possibly transitioning to illicit drugs, including illicit fentanyl and heroin – this would be a separate group of patients distinguished from those with substance use disorders (evidenced by Task Force public comments). The Centers for Disease Control and Prevention (CDC) has recently noted that the opioid crisis is quickly moving to a fentanyl crisis.14 This has coincided with an increase in the demand of the illicit drug market for synthetic opioids as well as other substances,15,16 and with a four-fold increase in the heroin death rate since 2010.17 Nationwide, nearly half of all opioid overdose deaths in 2017 involved illicitly manufactured fentanyl. Fentanyl is an opioid used for pain and anesthesia and is 50 times more potent than morphine. Illicit fentanyl (manufactured abroad and distinct from medical use in the United States), with an even more potent synthetic form, has sometimes been mixed with other opioids (prescription and illicit opioids, cocaine, and other illegal substances), including heroin, resulting in sentinel outcomes because of its concentrated effect and low costs.

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Public comments submitted to the Task Force show growing consideration of suicide resulting from unrelieved pain and in some cases 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 who also had evidence of chronic pain increased from 7.4% in 2003 to 10.2% in 2014.18 Numbers from this data set beyond 2014 are not yet available. This finding leads to the rising concern that a recent trend of health care professionals opting out of treating pain has contributed to an existing shortage of pain management specialists1 and is leaving some patients without adequate access to care.

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 common mental health co-morbidities such as anxiety and depression or by addiction. Opioids can have addictive properties in certain 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 and education about these issues, opioid misuse has since been decreasing, from 12.8 million individuals in 2015 to 11.4 million individuals in 2017.19

HHS is advancing a comprehensive overview that addresses all issues in the practice of acute and chronic pain management, an effort that is coordinated with the 5-Point Strategy to Combat the Opioid Crisis to recalibrate the role opioid medications play in pain care to reduce opioid harm and improve the QoL for patients living with pain.12 This work includes execution of mandates set forth by the Comprehensive Addiction and Recovery Act (CARA), which establishes “an interagency task force, convened by the Department of Health and Human Services, in conjunction with the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the White House Office of National Drug Control Policy.”20 The CARA legislation instructs the Task Force to “[d]etermine 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.”20

The Task Force recognizes that comprehensive pain management often requires the work of various health care professionals, including physicians, dentists, nurses, pharmacists, physical therapists, occupational therapists, behavioral health specialists, psychologists, 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, such as delayed recovery from surgery or an activation of behavioral and emotional disorders. Achieving excellence in patient-centered care depends on a strong patient-clinician relationship defined by mutual trust and respect and, in the case of chronic pain, empathy and compassion on the part of the health care provider.21 As required by congressional legislation, HHS has convened the Task Force, which consists of 29 members with expertise in pain management, patient advocacy, substance use disorders (SUDs), mental health, state medical boards, minority health, and veteran service organizations as well as other organizational representatives. The Task Force includes representatives from federal agencies, including HHS, the VA, DoD, and the Office of National Drug Control Policy.

In 2018, the Task Force convened two public meetings that included extensive public comment and critical patient testimonials from various different patient groups. There were numerous subcommittee meeting deliberations and discussions that included various special population presentations, including the Indian Health Services (IHS), the Defense Health Agency, the VA, state health officials, private and industry experts, and integrative pain experts. The Task Force reviewed extensive public comments, patient testimonials, and existing best practices; considered relevant medical and scientific literature; and requested information from government and nongovernment experts in pain management and related disciplines. Task Force discussion and analysis resulted in the identification of gaps, 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 needed updates to best practices, or a need to reemphasize vital best practices. Gaps and recommendations in the report span five major interdisciplinary treatment modalities: medication, restorative therapies, interventional procedures, behavioral health approaches, and complementary and integrative health. This report also 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, education, and access to care. The report reviews various clinical practice guidelines (CPGs), with 2018 public comments from key stakeholders, patients, family members, as well as the CDC guideline.

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2. Clinical Best Practices

CPGs are designed to provide evidence-based information and assist in clinical decision making to optimize patient care and outcomes. In pain management, a critical part of providing comprehensive care is performance of a thorough initial evaluation, including assessment of both the medical and the probable biopsychosocial factors causing or contributing to the pain, with a treatment plan to address the causes of pain and to manage pain that persists despite treatment. Quality pain management and CPGs can alter opioid prescribing both by offering alternatives to opioids and by clearly stating when they may be appropriate and how to consider risk assessment and benefit analysis with ongoing nonopioid treatment modalities.3 Several recent CPGs for chronic pain management agree on specific recommendations for mitigating opioid-related risk through risk assessment, including screening for risks such as depression, active or prior history of SUDs, family history of SUD, and childhood trauma, among other issues, 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. CPGs 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 by nonopioid approaches.

To continue improving quality of pain care in the current environment of opioid-related risks, experts have noted several key challenges associated with CPGs. 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, demographics, and settings (e.g., hospital, perioperative, primary care, emergency department [ED]). Second, there must be improved access to effective pain management treatments through adoption of CPGs in medical practice and clinical health systems.22 Third, CPGs for pain management should be more incorporated into the routine training of clinicians,23 with special attention to residency training to meet the needs of patients treated in each specialty.3,10 Finally, there needs to be adequate reimbursement for quality care.

Pain management experts have also identified specific research gaps that are impeding the improvement of pain management guidelines as well as other needs, including synthesizing and tailoring recommendations across guidelines, diagnoses, and populations. In addition, there are gaps and inconsistencies within and between pain management and opioid prescribing guidelines.24-26 This finding is also the result of demographic and other variances, because clinical best practices (CBPs) are developed in different regions and states around the country. A recent review of clinical opioid prescribing guidelines by Barth et al.27 notes several needs — including the development of postoperative pain management guidelines for different surgical procedures, with the understanding of patient variability in physiology, drug metabolism and other medical underlying disease processes. This further emphasizes the need for an individualized patient-centered approach. In light of these gaps, there are potential limitations to evidence-based clinical recommendations that should be considered by pain management providers.28

A systematic review of CPGs for neuropathic pain29 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 a consensus in guideline development.30 A review of state-level guidelines for opioid prescriptions found that a minority of states had guidelines specific to EDs.31 Pain guidelines from the World Health Organization are facing a lack of adoption, potentially because they lack incorporation of contemporary pain management practices.32

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2.1 Approaches to Pain Management

A multimodal approach to pain management consists of using more than one treatment modality from one or more medical disciplines to be incorporated into a pain treatment plan. Such modalities allow for different approaches to address the pain condition (acute and chronic) from a variety of mechanisms, often allowing for a synergistic approach that addresses the different aspects of the pain condition, including addressing improved symptoms and functionality. Multidisciplinary approaches incorporate various disciplines to address different components of chronic, often complex pain conditions including biopsychosocial effects of the medical condition on the patient.33–35 The efficacy of such a coordinated, integrated approach has been documented in the scientific literature to reduce pain severity, improve mood and overall QoL, and increase function.34,36-41 HHS has developed a National Pain Strategy that “recommends a population-based, biopsychosocial approach to pain care that is grounded in scientific evidence, integrated, multimodal, and interdisciplinary, while tailored to an individual patient’s needs.”42 Recent CPGs developed by the VA and DoD integrate the biopsychosocial model of pain,26 and the Veterans Health Administration (VHA) has identified biopsychosocial care plans as an essential element to effective pain management.43 The biopsychosocial approach is applied clinically across pain experiences, including chronic pain,44 and specifically to musculoskeletal pain,45 low-back pain,46,47 and HIV-related pain.48 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.

Gaps and Recommendations

Gap 1: Current inconsistencies and fragmentation of pain care limit best practices and patient outcomes. A coherent policy for pain management within health systems is needed.

Recommendation 1a: Encourage coordinated and collaborative care that allows for best practices and improved patient outcomes whenever possible. One of many examples is the collaborative stepped model of pain care, as adopted by the VA and DoD health systems.

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2.1.1 Acute Pain

Acute pain is a ubiquitous human experience49 that is classified as a physiologic response to noxious stimuli that is sudden in onset and time limited.50 Acute pain can occur after an injury, burn, or trauma or following surgery in the perioperative period. Acute pain and chronic pain are often interlinked, with nearly all cases of chronic pain beginning as acute pain.51 Acute pain flares may recur periodically in common and complex chronic medical problems, including as examples, but not limited to arthritis,52 neuropathies,53 spinal conditions, low-back pain,54 sickle cell disease (SCD),55 migraine,56 multiple sclerosis (MS),57 trigeminal pain or neuralgia,58 and complex regional pain syndrome (CRPS).59 As with acute pain flares in these and other conditions, it is important to perform a thorough evaluation — one that leads to a presumed diagnosis or differential diagnosis — that facilitates both diagnostic and therapeutic plans. The optimal management of acute pain should include establishing a diagnosis and overall treatment plan with continuity of care.60 It is vital to consider a risk-benefit analysis with a risk assessment approach to provide the best possible patient-centered outcome while mitigating unnecessary opioid exposure. To avoid the side effects associated with the prescription of opioids (e.g., nausea, vomiting, constipation, sedation, opioid use disorder [OUD], addiction), it is important to acknowledge the benefits of multimodal, nonopioid approaches in acute pain management in conjunction with possible opioid therapy.61 Reevaluation of patient 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 function to optimize outcome following surgery or injury. Although opioids are effective in treating acute pain, 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 patients with tobacco use, alcohol and substance abuse disorders, anxiety, depression, other pain disorders, and comorbid conditions.62 This finding further underscores the value and importance of initial clinician-patient time together as well as appropriate follow-up time to better assess risk and provide appropriate treatment for these complex pain conditions.

Gaps and Recommendations

Gap 1: Multimodal, nonopioid therapies are underutilized in the perioperative setting.

Recommendation 1a: Use procedure-specific, multimodal regimens and therapies when indicated in the perioperative period, including various nonopioid medications, ultrasound-guided nerve blocks, analgesia techniques (e.g., lidocaine and ketamine infusions), and psychological and integrative therapies to mitigate opioid exposure.

Use procedure-specific, multimodal regimens and therapies when indicated in the perioperative period, including various nonopioid medications, ultrasound-guided nerve blocks, analgesia techniques (e.g., lidocaine and ketamine infusions), and psychological and integrative therapies to mitigate opioid exposure. Recommendation 1b: Use multidisciplinary and multimodal approaches for perioperative pain control (e.g., joint camps, Enhanced Recovery After Surgery [ERAS], Perioperative Surgical Home [PSH]). Key components may include preoperative psychology screening and monitoring; preoperative and postoperative consultation and planning for managing pain of moderate to severe complexity; preventive analgesia with preemptive analgesic nonopioid medications; and regional anesthesia techniques, such as continuous catheter-based local anesthetic infusion.

Use multidisciplinary and multimodal approaches for perioperative pain control (e.g., joint camps, Enhanced Recovery After Surgery [ERAS], Perioperative Surgical Home [PSH]). Key components may include preoperative psychology screening and monitoring; preoperative and postoperative consultation and planning for managing pain of moderate to severe complexity; preventive analgesia with preemptive analgesic nonopioid medications; and regional anesthesia techniques, such as continuous catheter-based local anesthetic infusion. Recommendation 1c: Develop appropriate reimbursement and authorization 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.

Gap 2: Guidelines for the use of multimodal clinical management of the acute pain associated with common categories of surgical interventions and trauma care are needed.

Recommendation 2a: 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.

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, 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.

Emphasize the following in guidelines, which provide an initial pathway to facilitate clinical decision making:

To reflect multidisciplinary approaches and the biopsychosocial model for management of acute and chronic pain, 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. The following section focuses on special populations that face unique challenges in acute and chronic pain management.

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2.2 Medication

Effective pain management, particularly for chronic pain, is best achieved using a patient-centered, multidisciplinary, multimodal, integrated approach that may include pharmacotherapy.42,46,63 In general, two broad categories of medications are used for pain management: opioids and a variety of nonopioid classes of medications.64,65

In response to the public health crisis resulting from the current opioid epidemic, there is a surge of interest in nonopioid pharmacotherapies for chronic pain.66-68 Nonopioid medications that are commonly used include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants (e.g., serotonin-norepinephrine reuptake inhibitors [SNRIs] and tricyclic antidepressants [TCAs]), anticonvulsants, musculoskeletal agents, and anxiolytics.68-71 Nonopioid modalities, including these medications, can mitigate and minimize opioid exposure. Each medication has its own risks and benefits as well as mechanism of action. Different medications can complement one another, and their effects 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.

The following paragraphs briefly describe nonopioid medications, 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 describes examples of common nonopioid 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 effects and risks of these medications. Over-the-counter medications can be present in or components of common cold and cough medicine; therefore, it is necessary to ensure that patients are aware of and discuss their medications with their doctor and/or their pharmacist.

Acetaminophen can be effective for mild to moderate pain. Risks of acetaminophen can include dose-dependent liver toxicity, especially when taken at high doses or by those with liver disease.72 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 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 cyclooxygenase [COX]-1 and COX-2 enzymes) can be associated with gastritis, gastric ulcers, and gastrointestinal bleeding. Conversely, COX-2 inhibitors have less gastrointestinal adverse effects. The use of certain NSAIDs may be associated with renal insufficiency, hypertension, and cardiac-related events.

Anticonvulsants are medications originally developed to treat seizures but are also commonly used to treat different pain syndromes, including postherpetic neuralgia, peripheral neuropathy, and migraine.73,74 They are often used as part of a multimodal approach for the treatment of pain in the perioperative period. Some of these agents can be effective in treating the neuropathic components of pain syndromes. Anticonvulsants, which include gabapentinoids, may cause significant sedation and have recently been associated with a possible risk of misuse.75

Antidepressants are commonly used in various chronic pain conditions.73,76 Tricyclic antidepressants are effective medications for a variety of chronic pain conditions, including neuropathic pain. As with other medications, they can have risks and adverse effects, including dry mouth, dizziness, sedation, memory impairment, orthostatic hypotension, and cardiac conduction abnormalities. Trials with different TCAs (e.g., desipramine, nortriptyline, amitriptyline) should be initiated at a low dose and gradually titrated to optimal effect. SNRIs, such as venlafaxine and duloxetine, are effective for a variety of chronic pain conditions, including musculoskeletal pain, fibromyalgia, and neuropathic pain conditions, but with markedly fewer adverse effects (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.77 Although selective serotonin reuptake inhibitors, such as fluoxetine, sertraline, citalopram, and paroxetine, are effective antidepressants, they have less analgesic effect compared with other antidepressant classes. Overall, the analgesic actions of antidepressants occur even in patients who are not clinically depressed, and their analgesic effect typically occurs sooner and at lower doses than are required for the treatment of depression.

Musculoskeletal agents commonly used for pain treatment include baclofen, tizanidine, and cyclobenzaprine (a TCA). Carisoprodol is metabolized to meprobamate, which is both sedating and possibly addictive, and so the use of carisoprodol is not recommended, particularly because alternatives are available.78

Anxiolytics, including benzodiazepines, are often prescribed for anxiety and stress associated with chronic pain. Benzodiazepines do not have independent analgesic effects but can have indirect pain-relieving effects because of other mechanisms of action79 . Caution must be used with benzodiazepines because of the potential for substance use disorder. Co-prescription of benzodiazepines and opioids is associated with enhanced risks of overdose, respiratory depression, and death.80-82 Combining opioids and benzodiazepines can be unsafe because both types of drugs sedate users and suppress breathing — the cause of overdose fatality — in addition to impairing cognitive function.83

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The following paragraphs briefly describe opioid medications, 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.

Opioids are broad-spectrum analgesics that provide pain relief for a wide variety of conditions. Administration of opioid medication can include short- versus long-acting formulations84 and different delivery modalities, such as oral, intravenous, per-rectum, transdermal patches85 and lozenge formulation. Opioids bind to opioid receptors in the brain, spinal cord, and other sites, activating analgesic and reward pathways.86 It is important to point out that different opioid medications vary in the ratio of their analgesic potency and their potential for respiratory depression, the major cause of opioid overdose death.87 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 overdose deaths in the United States, often because of its use in combination with illicitly obtained heroin, cocaine, diverted prescription opioids, and other drugs of abuse. Common prescription opioid medications that can be considered for management of acute and chronic pain include hydromorphone, hydrocodone, codeine, oxycodone, methadone, and morphine.88-91 Although effective for moderate to severe acute pain, the effectiveness of opioids beyond 3 months requires more evidence.92 A recent study concluded that treatment with opioids alone was not superior to treatment with trials of various combinations of nonopioid medications for improving pain-related function over 12 months, and the authors concluded that the results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.93 There are challenges to completing long-term studies of any therapy for moderate to severe pain, particularly patient drop-out from intolerable pain.94 Opioid medications can be associated with significant side effects, including constipation, sedation, nausea, vomiting, irritability, pruritis, and respiratory depression.95-97 Opioid medications can be associated with OUD98 and can be diverted.99 Buprenorphine is another medication that is FDA approved for pain management. Because buprenorphine is a partial agonist at the mu opioid receptor, it has a reduced potency for respiratory depression and is thus safer than full agonists such as morphine, hydrocodone, and oxycodone.100,101 In addition, buprenorphine acts as an antagonist at the kappa receptor, an effect shown to reduce anxiety, depression, and the unpleasantness of opioid withdrawal. Oral buprenorphine is widely used for treating patients with OUD but can also be effective and is approved for treatment of pain. There has been a noted challenge, however, by physicians in getting authorization for buprenorphine for pain.

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.26,102,103 Initiation of opioid therapy, when the benefits are deemed by the patient and the clinician to outweigh the risks, should be administered at the lowest dose of medication required to optimally control the pain or improve function and QoL and for the shortest period necessary.26,42,102 Similarly, assessing for tolerance and consideration of adjunctive therapies, opioid rotation, tapering, and discontinuation based on periodic reevaluation with risk assessment should be considered.26,102,104 Periodic reevaluation with continued risk assessment and accurate dose adjustment is critical because patients vary widely in the dose required for analgesic efficacy.105,106 Comprehensive risk assessments consider patient functionality, QoL, and potential comorbidities.26,42,102

The idea of a ceiling dose of opioids has been put forward, but establishing such a ceiling is difficult, and the precise level for such a ceiling has not been established.107 The risk of overdose increases with the dose, but the therapeutic window is highly variable. For example, the CDC guideline identified a dose limit of 90 morphine milligram equivalents (MMEs) per day. More recent data evaluated the risk of death related to opioid dose in 2.2 million North Carolinians and found that the overall death rate was only 0.022% per year.108 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.”

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ADDITIONAL CONSIDERATIONS

The following paragraphs briefly describe additional considerations relevant to medications used for pain management.

Synthetic opioids other than methadone (a category that includes prescribed fentanyl as well as illicit fentanyl) are now the leading opioid involved in overdose deaths in the United States.88-90 The source of illicit fentanyl has been identified as international and rarely from diverted fentanyl pharmaceuticals. These sources come through the U.S. Postal Service and other means. The illicit fentanyl analog used is not necessarily the same compound used during surgeries, nor in the transdermal fentanyl patches provided for moderate to severe pain. The illicit form that has been seen is an analog called carfentanil, which is 100 times more potent than regular fentanyl. The availability of naloxone as well as patient and family education about naloxone can mitigate the risks of fentanyl-related overdose.109

Interaction of multiple medications prescribed to patients (polypharmacy) can have signification clinical and symptomatic effect. Poison centers are available 24/7 to health care professionals and the public to answer questions about medication interactions and adverse effects and to assess the need to use emergency health care resources.110,111 Poison 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.112,113 Increased awareness by providers of the complex and variable interactions of medications prescribed to patients as well as any homeopathic, supplemental, or other over-the-counter remedies they may be using is needed.114

Abuse-deterrent technologies are being developed with the goal of preventing alterations of prescription opioid formulations and the extraction of the active ingredient by users.115,116 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.117 ADFs also include adding a pharmaceutical or chemical compound to the opioid to decrease the user’s response to the abused substance or provide an adverse reaction when the medication is altered.116 To address misuse of prescription opioids, the FDA released guidance in 2015 for the development of opioids formulated to meaningfully deter abuse.115 A challenge to the development of opioid ADFs is the need to maintain the same safety and efficacy profile as the opioid without the ADF for FDA approval.116,118,119

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Gaps and Recommendations

Gap 1: Clinical policies tend to treat the large population of patients with multiple conditions causing chronic pain with simple medication rules. Guidelines for medication use for specific populations of patients (e.g., different ages, genders, medical conditions, comorbidities) with chronic pain need to be developed for each specialty group and setting.

Recommendation 1a: Develop condition-specific treatment algorithms that guide physicians to have a more individualized approach for common pain syndromes and conditions. A multidisciplinary approach that integrates the biopsychosocial model is recommended.

Develop condition-specific treatment algorithms that guide physicians to have a more individualized approach for common pain syndromes and conditions. A multidisciplinary approach that integrates the biopsychosocial model is recommended. Recommendation 1b: Primary care and non-pain specialists should have timely, early consultation with the pain medicine team and other specialists for the assessment of patients with complex pain to prevent complications and loss of function and to improve QoL.

Primary care and non-pain specialists should have timely, early consultation with the pain medicine team and other specialists for the assessment of patients with complex pain to prevent complications and loss of function and to improve QoL. Recommendation 1c: Develop a collaborative, multimodal treatment plan among the referring physician, the pain medicine team, and the patient.

Develop a collaborative, multimodal treatment plan among the referring physician, the pain medicine team, and the patient. Recommendation 1d: Pharmacies should collaborate with area physicians and other health care providers to develop more effective 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 primary care providers (PCPs) on appropriate pain treatment approaches.

Recommendation 2a : Use of nonopioid medications (e.g., oral and IV acetaminophen, oral and IV NSAIDs, long-acting local anesthetics, dexmedetomidine), with nonpharmacologic treatments, should be used as first-line therapy whenever possible in the in-patient and out-patient settings.

Use of nonopioid medications (e.g., oral and IV acetaminophen, oral and IV NSAIDs, long-acting local anesthetics, dexmedetomidine), with nonpharmacologic treatments, should be used as first-line therapy whenever possible in the in-patient and out-patient settings. Recommendation 2b: If an opioid is being considered, physicians and other health care providers should use evidence-informed guidelines.

If an opioid is being considered, physicians and other health care providers 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 need and pain condition.

The type, dose, and duration of opioid therapy should be determined by treating clinicians according to the individual patient’s need and pain condition. Recommendation 2d: Opioid therapy should be initiated only with ongoing nonopioid treatments when the benefits outweigh the risks; the patient is experiencing severe acute or chronic pain that interferes with function; 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.

Opioid therapy should be initiated only with ongoing nonopioid treatments when the benefits outweigh the risks; the patient is experiencing severe acute or chronic pain that interferes with function; 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: The Centers for Medicare & Medicaid Services (CMS) and payors should provide reimbursement that aligns with the medication guidelines the Task Force has described.

Gap 3: There is often a lack of understanding and education regarding the clinical indication and effective use of nonopioid medications as part of a multimodal and multidisciplinary approach to acute and chronic pain management. Chronic pain is often ineffectively managed, which can in part be the result of a variety of factors, including physician training, patient access, and other barriers to care:

Recommendation 3a: Physicians and other health care providers should understand the use of nonopioid medication and their mechanism-based pharmacology for managing different components of pain syndromes.

Physicians and other health care providers should understand the use of nonopioid medication and their mechanism-based pharmacology for managing different components of pain syndromes. Recommendation 3b: For neuropathic pain, consider antineuropathic medication, including TCAs; anticonvulsants (e.g., gabapentin, pregabalin, carbamazepine, oxcarbazepine); SNRIs (e.g., duloxetine, venlafaxine); and topical analgesics, such as lidocaine and capsaicin. Regardless of the route of medication, education regarding the side effects and risks and benefits is vital in terms of understanding clinical indications and patient outcomes.

For neuropathic pain, consider antineuropathic medication, including TCAs; anticonvulsants (e.g., gabapentin, pregabalin, carbamazepine, oxcarbazepine); SNRIs (e.g., duloxetine, venlafaxine); and topical analgesics, such as lidocaine and capsaicin. Regardless of the route of medication, education regarding the side effects and 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. Further classes of medication depend on the patient’s response and can include (depending on specific pain syndromes) an indication for muscle relaxants (e.g., tizanidine, baclofen) and topical agents in addition to other multimodal approaches. Additional consideration should be given to SNRIs indicated for chronic musculoskeletal pain.

Gap 4: Barriers, such as lack of coverage and reimbursement and understanding of proper usage, limit access to buprenorphine treatment for chronic pain:

Recommendation 4a: Make buprenorphine treatment for chronic pain available for specific groups of patients, and include oral buprenorphine for third-party payors with hospital formularies.

Make buprenorphine treatment for chronic pain available for specific groups of patients, and include oral buprenorphine for third-party payors with hospital formularies. Recommendation 4b: Provide coverage and reimbursement for buprenorphine treatment approaches.

Gap 5: There is currently inadequate education for patients regarding safe medication storage and appropriate disposal of excess medications targeted at reducing outstanding supplies of opioids that may be misused by others or inadvertently accessed by children and other vulnerable members of the household.

Recommendation 5a: Increase public awareness of poison 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.

Increase public awareness of poison 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: The US Drug Enforcement Administration (DEA) should increase opportunities for safe drug disposal and drug disposal sites (i.e., pharmacies, police departments, fire departments).

The US Drug Enforcement Administration (DEA) should increase opportunities for safe drug disposal and drug disposal sites (i.e., pharmacies, police departments, fire departments). Recommendation 5c: Adopt neutralization technologies that may make safe disposal more readily available.

Adopt neutralization technologies that may make safe disposal more readily available. Recommendation 5d: Include partial fills of C-2 drug classes.

Include partial fills of C-2 drug classes. Recommendation 5e: Educate veterinarians on the importance of safe storage and disposal of opioid medications in their practice. In addition, educate pet owners about the importance of safe storage and disposal of opioid pain medication prescribed for their pets.

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2.2.1 Risk Assessment

The selection of the most appropriate medication-based treatment approach for an individual with pain involves a careful analysis of risk and benefit. Risks of side effects and toxicity — and costs — must be balanced against the benefits of the treatment, including improved function with improved QoL, activities of daily living (ADLs), maintaining 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 minimize potential adverse consequences and facilitate treatment or referral for treatment of active SUDs.

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2.2.1.1 Prescription Drug Monitoring Programs

Prescription drug monitoring programs (PDMPs) are state-managed electronic databases of controlled substances dispensed (typically schedule II – IV), with the majority of the data being reported by community-based pharmacies.120 PDMPs allow 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 (so, almost all 50 states) and the District of Columbia have operational PDMPs.121,122

Prescribers may be required to use PDMP data at the point of care, allowing them to identify patients with 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 the potential that patients are at risk of 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, making referrals to mental health or substance abuse treatment.123,124 McAllister et al.125 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 also important for pharmacists to know that doctors often work as teams and to ensure that “doctor shopping” is a conclusion made after the pharmacist has made contact with the provider.

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 CDC’s Guideline for Prescribing Opioids for Chronic Pain.126 Clinicians should review PDMP data when starting patients on opioid therapy for chronic pain and periodically during opioid therapy for chronic pain.126

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.127 Requiring PDMP checks also has a positive effect. Buchmueller and Carey128 found stronger effects 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 effect. 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.125

Baehren et al.129 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 had been originally planned by the physician 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 effective use of PDMP data is beneficial to both health care professionals and patients.

The need to modernize and enhance functionality of PDMPs is widely acknowledged. 130-133 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.134 EHRs should work to integrate PDMPs in 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.131 Provider PDMP adoption has been shown to fall when interoperability is low and use is not mandated.135 Accessing PDMP data also affects the VA and IHS. VA physicians noted that incomplete or unavailable data was a significant barrier to increasing PDMP use.136 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 memoranda of understanding were signed with the appropriate state offices.42,137 Linkage to and use of PDMPs varies across IHS service areas.

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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: Check PDMPs, in conjunction with other risk stratification tools, upon initiation of opioid therapy, with periodic reevaluation.

Check 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.

Provide clinician training on accessing and interpreting PDMP data. Recommendation 1c: Physicians and other health care providers 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 is not error proof and should not be used to dismiss patients from clinical practices.

Physicians and other health care providers 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 is not error proof and should not be used to dismiss patients from clinical practices. Recommendation 1d: The health care provider team should determine when to use PDMP data. PDMP use should not be mandated without proper clinical indications to avoid unnecessary burden in the inpatient setting.

The health care provider team should determine when to use PDMP data. PDMP use should not be mandated without proper clinical indications to avoid unnecessary burden in the inpatient setting. Recommendation 1e: Conduct studies to better identify where PDMP data is 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 overutilization of resources (i.e., streamline PDMP data use).

Recommendation 1f: EHR vendors 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.

EHR vendors 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. Recommendation 1g: Enhance the interoperability of PDMPs across state lines to allow for more effective use.

Enhance the interoperability of PDMPs across state lines to allow for more effective use. Recommendation 1h: Physicians and other health care providers within and outside federal health care entities should have access to each other’s data to ensure safe continuity of care.

Physicians and other health care providers within and outside federal health care entities should have access to each other’s data to ensure safe continuity of care. Recommendation 1i: Include all opioid prescribers, including physician and nonphysician providers and dentists, in PDMPs.

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2.2.1.2 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 be done to screen for risk factors and characterize pain to inform treatment decisions. Screening approaches to assess for concurrent substance use and mental health disorders that may place patients at higher risk for OUD and overdose include screening for drug and alcohol use and the use of urine drug testing.69,138 These approaches seek to 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.139

Screening tools can help clinicians identify risks in individual patients that can be help in identifying which medication classes may be appropriate for the patient, including for long-term opioid therapy. Effective 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?”140 Other validated screening tools include the Drug Abuse Screening Test141 and the Alcohol Use Disorders Identification Test.142 Clinicians must recognize the limits of screening tools in detecting prior or developing SUD or OUD. There should also be screening tools to address the long-term use of nonopioids and potential for overuse, including NSAIDS causing renal, gastric, and cardiac issues and acetaminophen overuse causing serious liver issues, especially in medications that are over the counter and combine these medications in a manner that patients may not be aware of.

Urine drug tests (UDTs) can provide information about drug use that is not reported by the patient, 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 the Agency for Healthcare Research and Quality (AHRQ), there is a lack of evidence demonstrating the effectiveness of UDTs for risk mitigation during opioid prescribing for pain.143,144 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 UDT,138 and opioid treatment agreements,145 likely in part because of competing clinical demands, perceived inadequate time to discuss the rationale for UDT and to order confirmatory testing, and feeling unprepared to interpret and address results.146

To mitigate the risks of prescription opioid misuse, medical societies, 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. (Starrels et al., 2010).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.147 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.145

Monitoring approaches should be applied transparently and consistently in a manner that emphasizes safety so that miscommunication and accidental stigmatization is minimized.148 At follow-up, doctors should assess benefits in function, pain control, and QoL using tools such as the three-item “Pain average, interference with Enjoyment of life, and interference with General activity” Assessment Scale149 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.150 Clinicians should ask patients about their preferences for continuing opioids, given their effects on pain and function relative to any adverse effects experienced.126 These factors illustrate the importance of time with the patient that allows the doctor to thoroughly evaluate the patient.

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Gaps and Recommendations

Gap 1: Comprehensive screening and risk assessment of patients is time-consuming but vital for proper evaluation of their chronic pain conditions. Lack of sufficient compensation for time and payment for services have contributed to barriers in best practices for opioid therapy.

Recommendation 1a: Provide sufficient 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). These are vital aspects of risk assessment and stratification for patients on opioids and other medications.

Provide sufficient 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). These are vital aspects of risk assessment and stratification for patients on opioids and other medications. Recommendation 1b: Consider referral to pain and other specialists 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.

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: Physicians and other health care providers should educate patients on the use of UDTs and their role in identifying both potential inappropriate use and appropriate use.

Gap 3: There is variability in what is included in opioid treatment and opioid agreements.

Recommendation 3a: Conduct studies to evaluate the effectiveness of the different components of opioid treatment agreements. Treatment agreements should include the responsibilities of both the patient and the provider.

Conduct studies to evaluate the effectiveness of the different 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 risks and benefits of and alternatives to chronic opioid therapy.

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2.2.2 Overdose Prevention Education and Naloxone

Naloxone is a medication designed to rapidly reverse opioid overdose.151,152 It is an opioid antagonist that binds to opioid receptors and can reverse and block the effects of other opioids. It can very 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,153 and both intramuscular or 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.154

Gaps and Recommendations

Gap 1: Bystander/take-home naloxone distribution is associated with a cost-effective reduction in mortality as well as improved connection to OUD; however, distribution is not widely available.

Recommendation 1a: Provide naloxone co-prescription/dispensing and education for patients and family members when the patient is on long-term opioids.

Provide naloxone co-prescription/dispensing and education for patients and family members when the patient is on long-term opioids. Recommendation 1b : Increase naloxone distribution programs and education for first responders.

Increase naloxone distribution programs and education for first responders. Recommendation 1c: Research the potential risks and benefits of making naloxone available over the counter.

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2.3 Restorative Therapies

Restorative therapies include physical therapy (PT), occupational therapy (OT), 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 different providers, including physical therapists and occupational therapists, 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 following paragraphs briefly describe restorative therapies, 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 describes just a few examples of common restorative therapies.

The role of therapeutic exercise in the treatment of pain is tied to the underlying diagnosis responsible for the pain. Bed rest was scientifically recognized and prescribed as a treatment for low-back pain as recently as the 1980s,155 but high-quality scientific evidence has since emerged establishing the superiority of movement therapies over rest.156 The majority of pain-related PT guidelines exist for the treatment of spinal pain. In addition to improving physical functioning, a more contemporary biopsychosocial treatment approach to therapeutic exercise helps patients understand and overcome “secondary pathologies,” including fear of movement, pain catastrophizing, and anxiety, that contribute to pain and disability.”45

Transcutaneous electric nerve stimulation (TENS) has been applied to treat pain, but studies of its efficacy are lacking in number and design, with high risks of bias commonly reported.157 An evaluation of 49 systematic reviews, randomized clinical trials (RCTs), and observational studies found insufficient evidence to assess the effectiveness of TENS for acute low-back pain.158 More recent individual studies have investigated the effectiveness of TENS for postpartum pain,159 phantom limb pain,160 and knee osteoarthritis.161 Despite the overall limited evidence of efficacy, partially stemming from a lack of large RCTs, TENS is considered a safe self-care option for patients with appropriate education.162

Massage therapy can be effective in reducing pain.163 There are a variety of types of massage therapy, including Swedish, shiatsu, and deep tissue (myofascial release).164,165 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 technique from the PT field that is used to treat spinal pain. Review of the evidence has failed to demonstrate the clinical effectiveness of traction as an effective, evidence-based best practice; however, the filed in general lacks high-quality RCTs that examine effectiveness of traction as an isolated treatment modality for low-back158,166 or neck pain.167

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 used as a component of the RICE (rest, ice, compression, elevation) paradigm for the treatment of acute pain syndromes. Because it treats only symptoms, the effects 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.168 Evidence is not robust for all locations and types of pain, but there is significant evidence for the efficacy and safety of heat wraps in specific conditions, most notably for acute low-back pain. In fact, a review of nonpharmacologic therapies found that superficial heat had good evidence of efficacy for treatment of acute low-back pain.169 Another review found moderate evidence for heat wraps for both symptom and functional improvements.158

Therapeutic ultrasound (TU) is thought to deliver heat to deep tissues for improved injury healing.170,171 A 2001 review concluded that there was little evidence that TU is more effective than placebo for pain treatment in a range of musculoskeletal conditions.172 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.173,174

Bracing has generally 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.175

Gaps and Recommendations

Gap 1: There is a lack of clarity on which restorative therapy modalities are indicated in the various pain syndromes.

Recommendation 1a: Conduct further research to provide evidence-informed data on which restorative therapy modalities are indicated as part of a multidisciplinary approach to specific pain syndromes.

Conduct further research to provide evidence-informed data on which restorative therapy modalities are indicated as part of a multidisciplinary approach to specific pain syndromes. Recommendation 1b : For those modalities where there are clear indications for benefits in the treatment of chronic pain syndromes (e.g., OT; PT; 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.

For those modalities where there are clear indications for benefits in the treatment of chronic pain syndromes (e.g., OT; PT; 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.

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2.4 Interventional Procedures

Interventional pain management is part of the pain specialty that applies image-guided and minimally invasive procedures toward the diagnosis and treatment of pain conditions.176 Many interventional procedures for pain 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.177 Diagnostic and therapeutic interventional techniques can be valuable options prior to the initiation of extensive surgical or opioid treatment or in concert with other treatment modalities. Additional research, with further evidence establishing clinical benefits of specific interventional procedures for specific pain conditions, would be beneficial and can further identify various procedures for specific clinical conditions,178 particularly for certain populations, such as children.179 Many interventional pain procedures are available on an outpatient basis, which is vital to ensuring access to care. Some minor interventional procedures may be performed in the primary care setting, while other more advanced procedures require specialty training. The definition of a successful outcome varies depending 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. Finally, in certain types of pain conditions where there is a specific physical cause of the pain, direct surgical intervention can be therapeutic and beneficial to patients.

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 describes just a few 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 tissues by eliminating the inflammatory compounds mediating nervous tissue irritation in the epidural space.180 ESIs are one the most common procedures in pain management and, in well-selected patients, can provide significant pain relief as part of a pain management plan.181 Although risks are associated with ESIs, they offer significant advantages to the patient, notably in that they may potentially reduce health care costs, health care utilization, and the need for future surgical intervention.182 Transforaminal epidural steroid injections 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) ablation183,184 or cryoneuroablation.185 Both of these procedures are used to treat a common cause of lower back pain as well as cervical neck pain caused by facet joint sprain (cervical whiplash) or degenerative changes and have proven effective in the treatment and diagnosis of cervical neck pain, axial back pain, and chronic spinal pain originating from facet joints.183,186-188 Compared with some intraspinal interventional treatments, procedures related to the facet joints can be simpler and lower risk.186

Cryoneuroablation is a specialized interventional pain management technique that uses a cryoprobe to freeze sensory nerves at the source of pain to provide long-term pain relief.189,190 Cryoneuroablation can be indicated for numerous persistent and intractable painful conditions; including temporomandibular joint (TMJ) pain, paroxysmal trigeminal neuralgia, chest wall pain,191 phantom limb pain, neuroma, peripheral neuropathy,191 knee osteoarthritis,192 and neuropathic pain caused by herpes zoster.189,193

RF Ablation. Conventional RF lesioning and pulse RF (PRF) are both means 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 conventional RF provides benefits in appropriate patients.190,194 PRF uses short, high-voltage bursts of energy produced by needles inserted next to nerves to “stun” nerves, thereby blocking transmission of pain signals.195,196 Although more research is required to better understand both the exact mechanism of action of PRF and its efficacy in treating various chronic pain syndromes, PRF has already demonstrated its potential as a promising interventional modality in the treatment of cervical radicular pain,197 though there is no current procedural terminology (CPT) code for the technique, and insurance usually does not cover it.

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Peripheral nerve injections, commonly referred to as peripheral nerve blocks (PNBs), are injections of local anesthesia frequently mixed with anti-inflammatory steroid medication or clonidine for both diagnostic and therapeutic pain relief purposes.198 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.199,200 PNBs are advantageous in that they allow for quicker discharge times in ambulatory settings, less postoperative nausea and vomiting because of less opioid medication use, 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 effective anesthetic blocks.201,202 Ultrasound has also improved the ability to diagnose and treat peripheral neuropathies, nerve entrapments,203,204 and PNBs can also have a role in potentially diminishing or preventing the development of chronic pain syndromes205,206 such as CRPS,207 headaches,208 pelvic pain,209 and sciatica.210

Similar to PNBs, sympathetic nerve blocks (SNBs) — injections of local anesthesia at the sympathetic nerve chain — can be used to diagnose or treat pain that involves the sympathetic nervous system.211 SNBs have been used to treat neuropathic pain, CRPS, and reflex sympathetic dystrophy as well as manage chronic abdominal, pelvic pain, and perineal pain.212-214

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 system. 215,216 Spinal cord stimulation using a variety of waveforms and frequencies and dorsal root ganglion stimulation, collectively, have five level-1 studies demonstrating their efficacy in low-back and lower extremity pain.217-221 Peripheral nerve stimulation has gained popularity and effectiveness 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. There are now multiple level-1 studies and multiple level-2 studies demonstrating that noninvasive vagus nerve stimulation can be effective in ameliorating pain in various types of cluster headaches and migraines.222-224 These therapies provide an electric field to the brain, cranial nerves, or peripheral nerves without actually requiring a surgical procedure or implant.

Intrathecal Pain Pumps. Because there are opioid receptors on the spinal cord and at specific areas of the brain, small 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 cancer as well as noncancer pain.225 The largest trial ever performed in cancer patients demonstrated improved pain control and fewer side effects and had a trend toward improved life expectancy with implantable pumps.226 However, there are significant side effects, including delayed respiratory depression, granuloma formation, and opioid-induced hypogonadism.227

Vertebral augmentation stabilizes the spine through the application of cement to vertebral compression fractures that are painful and refractory to medical treatment228; 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 effective vertebral augmentation procedures.229,230 Vertebral augmentation has also been combined with RF ablation to manage pain caused by vertebral damage secondary to fractures from various conditions or as a result of spinal metastases.231

Trigger points are palpable, tense bands of skeletal muscle fibers that, upon compression, are capable of producing both local and referred pain.232 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.232,233 Trigger point injections can be used therapeutically to treat pain associated with headaches, myofascial pain syndrome, and low-back pain.234-236 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.237,238 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.239

Interspinous Process Spacer Devices. Research has shown that interspinous process spacer devices can provide relief for patients with lumbar spinal stenosis with neuroclaudication.240,241

Regenerative/adult autologous stem cell therapy may show promise in the treatment of multiple painful conditions.242-244 Further research is needed and encouraged to investigate the potential of these therapies.

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Gaps and Recommendations

Gap 1: Interventional pain procedures can provide diagnostic information when evaluating patients in pain and provide therapeutic pain relief. A comprehensive assessment by a skilled pain specialist needs to be available to assess which particular procedure is indicated for a patient’s pain syndrome. Unfortunately, pain physician specialists are typically not involved in the multidisciplinary approaches of 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 primary care and pain medicine.

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 primary care and pain medicine. Recommendation 1b: Conduct additional clinical research that establishes how interventions work in conjunction with other approaches in the process of caring for chronic pain patients, especially early in the process, when combined appropriately with goal-directed rehabilitation therapy and appropriate medications.

Conduct additional clinical research that establishes how interventions work in conjunction with other approaches in the process of caring for chronic pain patients, especially early in the process, when combined appropriately with goal-directed rehabilitation therapy and appropriate medications. Recommendation 1c: Establish criteria-based guidelines for properly credentialing physicians who are appropriately trained using interventional techniques to help diagnose, treat, and manage patients with chronic pain.

Gap 2: There are inconsistencies and frequent delays in insurance coverage for interventional pain techniques that are clinically appropriate for a particular condition and context.

Recommendation 2a : 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.

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: 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 physicians and nonphysicians performing interventional procedures. This trend can potentially lead to serious complications and inappropriate utilization. For example, outside the Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs, there is currently little to no oversight over training requirements for interventional procedures.

Recommendation 3a: Establish credentialing criteria for minimum requirements for training physicians in interventional pain management.

Establish credentialing criteria for minimum requirements for training physicians in interventional pain management. Recommendation 3b: Only clinicians who are credentialed in interventional pain procedures should perform interventional procedures.

Only clinicians who are credentialed in interventional pain procedures should perform interventional procedures. Recommendation 3c: Clearly identify physicians who specialize in pain management by their training. This identification should be determined by ACGME-accredited pain medicine programs and by well-recognized credentials, such as the American Board of Pain Medicine (ABPM) and the American Board of Interventional Pain Physicians.

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2.4.1 Perioperative Management of Chronic Pain Patients

Perioperative pain management in chronic pain patients presents unique challenges,245,246 particularly for patients with opioid tolerance or those vulnerable to opioid-associated risks. Patients on long-term opioid therapy can be more complicated to manage in the perioperative period compared with patients who are opioid naive. Considerations for managing these patients include use of multimodal approaches as well as preoperative consultation and planning. In addition, behavioral interventions show promise for use in pre- and perioperative periods for the management of postsurgical pain.247-250 Other experts have suggested use of PSHs for this patient population.251 Chronic pain patients whose pain is managed by a clinician should have their pain management specialist consulted and involved in the planning of their pain control during and after the perioperative process.

Gaps and Recommendations

Gap 1: Chronic pain patients undergoing a surgical procedure often have complex issues that go unaddressed that may lead to incomplete and poor 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 pain population.

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2.5 Behavioral Health Approaches

In recent decades, pain management experts have recognized the important relationship between pain and psychological health.34,252,253 Psychological factors can play an important role in an individual’s experience and response to pain254,255 and can affect treatment adherence, pain chronicity, and disability status.252,256 Undiagnosed and untreated psychological concerns in individuals with pain are associated with increased health care utilization and readmissions, decreased treatment adherence, and increased disability.257-259 Chronic pain patients are at increased risk for psychological distress, maladaptive coping, and physical inactivity related to fear of reinjury.34 Individuals with chronic pain are more likely to have disabilities than patients with other chronic health conditions, such as stroke, kidney failure, cancer, diabetes, and heart disease.260 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 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.248,261

Behavioral health approaches as part of pain management are to be considered as 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.252,256,262 They target a variety of domains, including physical functioning, pain medication use, mood, cognitive patterns, and QoL.252

The following paragraphs briefly describe behavioral 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 their medical conditions. This list is not inclusive or exhaustive, but instead describes just a few examples of common behavioral health approaches.

Behavioral therapy (BT) for pain treatment 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 despite pain.263,264 BT has demonstrated effectiveness for reducing pain behaviors and distress and improving overall function, and it is more cost-effective than active physical treatment.265,266

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.267 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.252 The use of CBT for pain management is effective for a variety of pain problems268 and can help improve self-efficacy, pain catastrophizing, and overall functioning.269,270 The AHRQ found that CBT can lead to long-term improvements in patients with low-back pain and fibromyalgia.271

Acceptance and commitment therapy (ACT) is a form of CBT that emphasizes observing and accepting thoughts and feelings, li