In 2016, the Comprehensive Addiction and Recovery Act (CARA) was passed by the U.S. Congress. One of the provisions of this law was to create the "Pain Management, Best Practices Interagency Task Force," whose mission was 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."
There was a 90-day public comment period where ASA president David Miller, MD, LAc, in collaboration with other members of the Integrative Health Policy Consortium (IHPC), wrote a detailed response to HHS commending the Task Force for their thoughtful report and their specific inclusion of acupuncture in integrative teams as well as recommending movement therapies, such as tai chi and yoga.
The NCCAOM Advocacy Committee, which I also serve on, submitted a detailed response, highlighting important areas of focus moving forward.
Similar in spirit to the CDC Guidelines for Prescribing Opioids for Chronic Pain released in March, 2016, this report recommends a stepwise process for providers to follow beginning with nonpharmacologic treatment for pain (including acupuncture, massage therapy, physical and occupational therapies, cognitive behavioral therapy and meditation). From there, clinicians can prescribe non-opioid pharmacotherapy and finally opioid pharmacotherapy as the third, and last resort.
It lays out a multidisciplinary approach, breaking pain management into several areas:
- Medications
- Restorative therapies
- Interventional Procedures
- Complementary and integrative health
- Behavioral health/psychological therapies
Each of these sections contains a brief overview of the evidence of effectiveness, safety profile, duration of effect and other parameters, and the authors identify gaps to be filled in the future (greater insurance coverage/access to specific modalities, future research, credentialing for clinicians, workforce considerations, etc.).
My interest was immediately drawn to the Complementary and Integrative Health section of the report.
The authors assert that, "Clinicians are encouraged to consider and prioritize, when clinically indicated, nonpharmacologic approaches to the management of pain." This statement is in direct alignment with other pain policy documents such as the CDC Guidelines for Prescribing Opioids for Chronic Pain, the National Pain Strategy, the American College of Physicians Low Back Pain Clinical Guidelines and the FDA Pain Management Blueprint.
Here's where they're making recommendations in the AOM community's favor: "Improved reimbursement policies for complementary and integrative health approaches as well as improved education for medical professionals and a greater workforce of pain management specialists can address key barriers to acceptance and implementation of complementary and integrative health approaches for pain."
The specific therapies they address are acupuncture, massage and manipulative therapies, mindfulness based stress reduction, yoga, and tai chi. Their gaps and recommendations in this section include the following:
- Develop clinical practice guidelines for the application of complementary and integrative health approaches for specific indications.
- Conduct further research on complementary and integrative health approaches to determine therapeutic value, risk and benefits, mechanisms of action, and economic contribution to the treatment of various pain settings, including the acute perioperative surgical pain period and various other chronic pain conditions and syndromes.
- Consider the inclusion of various complementary and integrative health approaches as part of an integrated approach to the treatment of chronic pain, as clinically indicated, while evidence is further developed.
- Conduct further research on supplements such as alpha lipoic acid, L-carnitine transferase, and vitamin C and their effect on acute and chronic pain management.
A few forward-thinking recommendations outlined in the draft report include:
- Suggesting the Centers for Medicare & Medicaid Services (CMS) and other insurers align their reimbursement guidelines for non-opioid pharmacologic therapies with current clinical practice guidelines.
- Including acupuncture, mindfulness meditation, movement therapy, art therapy, massage therapy, manipulative therapy, spirituality, yoga, and tai chi, as nonpharmacologic options to pain management.
- Conducting more research on understanding the basic mechanisms of acute and chronic pain, and developing new safe and ef-fective treatments.
- Focusing research on complementary and integrative app-roaches to pain management, including risks, benefits, and cost effectiveness.
- Promoting patient-centered, integrative, multimodal care plans to address the public health crisis.
- Improving public, patient, and provider education about pain management.
- Emphasizing that proper pain management should be based on a biopsychosocial model of care.
- Shifting focus from pain care to preventative measures, espe-cially in high-risk populations, military/veterans, and underser-ved communities.
- Providing an empathetic, non-judgemental approach to those suffering from chronic pain or substance use disorder to improve outcomes since stigma is a major barrier to treatment.
- Improving access to integrative health care.
Some items notably absent from the report include:
- The role of nutrition and diet in the etiology and pathogenesis of pain conditions.
- Any use of topical or oral cannabidiol (CBD) or medical cannabis therapies. (Legalized medical cannabis is available in 33 states and the District of Columbia.)
- The value of support groups/counseling to assist those in pain to cope and recover.
- Homeopathic medications.
The draft report received blowback from New Mexico Attorney General Hector Balderas, who wrote a letter to HHS with 35 other Attorneys General. He said, "The opioid crisis has been devastating on our public health, social services and criminal justice systems. The suggestion that opioid providers can make up their own minds on distribution levels is incredibly dangerous considering their past practices. This will make a horrific opioid crisis even more deadly."
Furthermore, while tremendous recommendations are made, there aren't concrete strategies for implementation. Similar to the National Pain Strategy published in the spring of 2016, this report offers suggestions without "teeth." On the bright side, organizations such as the Joint Commission have created requirements for hospitals to use nonpharmacologic approaches to pain as first tier management options and this report may influence future health policy.
Since the public comment period passed (April 1, 2019), HHS will review all submitted comments and incorporate any edits or additions into their final report, which is expected to be made public by the summer or fall 2019. The final report will be submitted to Congress, and the NCCAOM Advocacy Advisory Committee and IHPC Policy Committee will subsequently disseminate the recommendations to the public, other federal agencies and the organization's stakeholders.
Kory Ward-Cook, PhD, MT, CAE, Chief Executive Officer of the NCCAOM said, "Overall, the final HHS report will be very beneficial for the acupuncture community - it represents a major push into improving access to complementary and integrative health, and we hope that the final report will be a stepping stone to improving coverage, reimbursement, research, and education around acupuncture for pain management."
John Weeks, journalist, editor, and writer of "The Integrator Blog" commented, "Over the past near decade since the passage of the affordable care act when the Academic Consortium of Integrative Health successfully got acupuncturist and naturopathic physician Rick Marinelli, ND, MAOM onto the National Academy of Medicine Committee to set a new course for pain care, we have seen a step-wise increase of integrative practices and practitioners – frequently cloaked as 'non-pharmacologic approaches' – into guiding documents for pain treatment. The HHS report is the most progressive yet, and hopefully this level of inclusion will be sustained in the final document."
Click here for more information about Bill Reddy, LAc, Dipl. Ac..