When It Comes To Managing Opioid Use, Can We Get A Little More Carrot Please?

Recently, there has been a lot of discussion in the United States about the use of opioids for treating chronic pain. On March 15, 2016, the Centers for Disease Control and Prevention (CDC) released the final version of its opioid prescribing guidelines. These guidelines generally discourage primary care physicians from prescribing opioids, and if doctors do prescribe opioids they are encouraged to do so at the lowest possible doses. The guidelines also recommend urine drug testing patients and state that nonpharmacologic therapy and nonopioid therapy should be preferred for treating chronic pain.

On March 29, President Obama gave some remarks at the National Rx Drug Abuse and Heroin Summit in Atlanta, Georgia, concerning the additional actions the Administration is taking to address the prescription opioid abuse and heroin epidemic. President Obama referenced the number 28,000 – which is how many people died of opioid overdoses in the United States in 2014. “It is important to recognize today we are seeing more people killed because of opioid overdoses than traffic accidents,” the President said. The President discussed plans to put together an infrastructure to help addicts get treatment more quickly, including his Administration calling for an additional $1 billion for drug treatment programs in this year’s budget.

While helping people who suffer from opioid addiction and preventing deaths from opioid overdoses is undoubtedly important, there has also been some concern within the chronic pain community that these measures aren’t doing much to actually help the 100 million people living with chronic pain. For example, the CDC guidelines recommend nonpharmacologic therapies, such as physical therapy, exercise therapy (including aerobic, aquatic, and/or resistance exercises), and weight loss. They also endorse psychological therapies, such as cognitive behavioral therapy (CBT), which is a form of therapy that works to change thinking and behavior. The guidelines continue by recommending the use of “integrated pain management,” which requires coordination of the medical, psychological, and social aspects of a patient’s care. This approach sounds like it would be of great use to people living with chronic pain, such as those diagnosed with rheumatoid arthritis. But the guidelines also recognize an unfortunate reality: “these therapies are not always or fully covered by insurance, and access and cost can be barriers for patients.”

As I see it, this is the major problem with our current approach to “the opioid epidemic.” We’ve already have plenty of sticks in place to discourage patients from using opioids – from burdensome regulations to social stigma to now, potentially, the need to be urine tested. But where are the carrots? Where are the recommendations and policies making the alternatives to opioids easier for patients to access and afford?

Hopefully, more comprehensive policies are on the way. On March 18, the Office of the Assistant Secretary for Health and the U.S. Department of Human Services released a National Pain Strategy (NPS). Developed by a diverse team of experts, the NPS outlines the federal government’s first coordinated plan for reducing the burden of chronic pain that affects millions of Americans.

According to the NPS, “when chronic pain develops, treatment should begin with a comprehensive assessment, followed by creation of a care plan that can evolve over time to address the full range of biological, psychological, and social effects of pain on the individual.” The NPS envisions a world in which “people experiencing pain would have timely access to patient-centered care that meets their biopyschosocial needs and takes into account individual preferences, risks, and social contexts.” In this vision, “clinicians would undertake comprehensive assessments of patients with chronic pain, leading to an integrated, patient-centered plan of coordinated care, managed by an interdisciplinary team, when needed. Treatment would involve high-quality, state-of-the-art, multimodal, evidence-based practices.” The NPS concludes “all people with pain should receive adequate care.”

Unfortunately, I think there is a great deal of work to be done before this vision can be come a reality in our current health care system. We need more treatments and we need better treatments – and these treatments need to be accessible and affordable. Research is needed to establish alternative therapies as viable treatment options, and insurance companies need to change their policies to cover these alternatives. Doctors need to be incentivized to actively counsel their patients, treat the “whole person,” and work as part of a team with other health care providers. And patients may need to re-think their willingness to try treatment options that require more effort on their part.

Still, I am hopeful that the NPS represents a step in the right direction.

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