On November 1st, 2017, Governor Chris Christie, et al. released a 138-page report entitled, "The President's Commission on Combating Drug Addiction and the Opioid Crisis" offering 56 recommendations to the Trump administration, none of which specifically referred to acupuncture as a viable solution.
The report also evaluated the CDC opioid prescription guidelines, prescription drug monitoring programs (PDMP), reducing the supply of illicit opioids, and drug addiction treatment and recovery programs. To any conventional medical practitioner, the commission report was quite comprehensive, however, to most acupuncturists, the report was woefully deficient of any holistic approaches to the epidemic.
For instance, take the following statement: "A good example of this federal leadership occurred when Department of Veterans Affairs Secretary Shulkin, in response to the Commission's interim report release, immediately launched eight best practices for pain management in the VA health-care system. These guidelines included everything from alternatives and complimentary care, counseling and patient monitoring to peer education for front-line providers, informed consent of patients and naloxone distribution for Veterans on long-term opioid therapy."
The proper term is "Complementary and Alternative Medicine (CAM)," not alternatives and complimentary care. "Complimentary" suggests there's no charge for the services. Obviously they didn't include any CAM professionals on the panel to write this report. The Integrative Health Policy Consortium (IHPC) includes the Academy of Integrative Pain Management as a "Partner for Health" and nominated their Executive Director, Bob Twillman, PhD to serve on the panel. Unfortunately, he wasn't chosen to participate.
It's a bit ironic that our government is turning to the pharmaceutical industry for solutions, when they're largely responsible for the opioid problem (creating two income streams). Here's the specific language from the report:
"National Institutes of Health (NIH) Director Dr. Francis Collins has been partnering with pharmaceutical companies to develop non-addictive painkillers and new treatments for addiction and overdose. The Commission worked with Dr. Collins to convene a meeting with industry leadership to discuss innovative ways to combat the opioid crisis."
Current Federal Programs And Funding Landscape
The President's FY 2018 Budget Request directs $27.8 billion for drug control efforts spanning prevention, treatment, interdiction, international operations, and law enforcement across 14 Executive Branch departments, the Federal Judiciary, and the District of Columbia.
Specific programs include the Comprehensive Addiction and Recovery Act, the 21st Century cures act, and other opioid-specific programs totaling $1.3 billion. Naloxone and necessary materials to assemble overdose kits will total $12 million distributed to 10 states. Acupuncture isn't even on their radar for high-risk communities. The graph (below) illustrates the federal drug resources by function. At a glance, it's obvious that prevention is low priority.
Addiction Treatment
The Commission report offered twenty recommendations under this heading. Here are two that may impact our profession:
- The Commission recommends HHS/CMS, the Indian Health Service (IHS), Tricare, the DEA, and the VA remove reimbursement and policy barriers to substance use disorder (SUD) treatment, including those, such as patient limits, that limit access to any forms of FDA-approved medication-assisted treatment (MAT), counseling, inpatient/residential treatment, and other treatment modalities, particularly fail-first protocols and frequent prior authorizations.
- The Commission recommends HHS review and modify rate-setting (including policies that indirectly impact reimbursement) to better cover the true costs of providing SUD treatment, including inpatient psychiatric facility rates and outpatient provider rates.
The first bullet lists "other treatment modalities" which could include acupuncture/NADA protocol. The second bullet recommendation will benefit us in the subset of healthcare systems that include covered acupuncture services.
Reimbursements for Non-Opioid Pain Treatments
The report clearly gave positive support for the use of acupuncture, but focused on existing barriers as insurmountable instead of proposing easy solutions to CMS limitations. The exact language is as follows: A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, chiropractic, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies, as well as health insurance providers and other payers, create barriers to the adoption of these strategies.
However, all is not lost. In late October 2017, the Academy of Integrative Pain Management held an Inaugural Integrative Pain Care Policy Congress in conjunction with IHPC and the State Pain Policy Advocacy Network to further strengthen the argument for greater insurance coverage of alternative pain care. The meeting offered a platform for dialogue between CMS and the VA who are currently offering acupuncture and other non-pharmacologic approaches to veterans with chronic pain, and have reduced opioid prescriptions by more than 80 percent.
The invitation-only meeting included 75 participants representing more than 50 organizations including state pain societies, health provider associations, integrative pain care-focused groups, insurers, policy makers and regulators, and palliative care organizations. Their aim was to identify and build deeper collaborative efforts around advancing integrative pain care, and the participants were very receptive to non-pharmacologic approaches like acupuncture, chiropractic and massage therapy. IHPC developed a repository for efficacy and cost effectiveness studies of various pain management approaches to share with all of the meeting attendees.
In a related effort, IHPC responded to a CMS request for information regarding their innovation center efforts, recommending: "The remaining and over-arching barrier that CMS can directly resolve is the inequitable status of reimbursement for services provided by state-licensed integrative providers, despite long-standing patient demand and robust clinical outcomes. What is more, these outcomes align directly with your objectives for promoting patient-centered care and market-driven reforms. Removing these unnecessary barriers will ensure that your Medicare and Medicaid beneficiaries have access to integrative healthcare services that are readily available right now in the market, but not yet available to them."
The nine-page letter included nine enclosures and 21 references specific to the efficacy and cost effectiveness of employing integrative approaches to pain and chronic disease. The cost savings scaled nationally to tens of billions of dollars.
Research and Development
The commission report offered five recommendations under this heading, one of which offers opportunities for education by our profession:
- The Commission recommends federal agencies, including HHS (National Institutes of Health, CDC, CMS, FDA, and the Substance Abuse and Mental Health Services Administration), DOJ, the Department of Defense (DOD), the VA, and ONDCP, should engage in a comprehensive review of existing research programs and establish goals for pain management and addiction research (both prevention and treatment).
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