Federal Task Force Releases ‘Roadmap’ to Treat Pain Crisis

By Pat Anson, PNN Editor

A federal advisory panel has released its final report on recommended best practices for acute and chronic pain management, calling for a balanced approach to pain treatment that focuses on individualized patient care – not rigid guidelines that triggered a pain crisis for millions of Americans.

“There is a no one-size-fits-all approach when treating and managing patients with painful conditions,” said Vanila Singh, MD, Task Force chair and chief medical officer of the HHS Office of the Assistant Secretary for Health. “Individuals who live with pain are suffering and need compassionate, individualized and effective approaches to improving pain and clinical outcomes. This report is a roadmap that is desperately needed to treat our nation’s pain crisis.”

Unlike previous federal efforts that focused primarily on limiting access to opioid medication while expanding access to addiction treatment, the 116-page report by the Pain Management Best Practices Inter-Agency Task Force took a more comprehensive approach to pain management that focused on the needs of patients, improving their quality of life, and establishing a “therapeutic alliance” between patient and clinician.   

The panel sought and received feedback from over 5,000 patients, advocates and healthcare providers on issues such as suicide, patient abandonment and the stigma associated with chronic pain. Several patient stories were incorporated into the final report.

Even longtime critics of federal pain care policies were impressed.

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“This report from the HHS Pain Management Task Force is exceptional, in my view. Rarely have I seen a report that is of such high quality, with such reasonable, common-sense recommendations,” said Bob Twillman, PhD, former Executive Director of the Academy of Integrative Pain Management. “The willingness to recognize concerns expressed by people with pain and by healthcare providers is not something we have often seen, and it is refreshing to see those comments play an important role here.”

“I truly hope this is a huge step forward,” said Andrea Anderson, a pain sufferer and patient advocate. “I think there was much to be praised, such as the focus on individualized patient care, the need for multi-disciplinary treatment teams with care-coordination, a more robust focus on post-surgical pain management, an emphasis on moving complementary and integrative health approaches into the main stream of pain treatment, and the need for further education and research  on a number of important topics.”

No Repeal of CDC Guideline

The task force did not call for a repeal of the CDC’s controversial opioid prescribing guideline, but said the guideline should be clarified and updated with better evidence to supports its recommendations..

“The Task Force recognizes the utility of the 2016 CDC Guideline for many aspects of pain management and its value in mitigating adverse outcomes of opioid exposure. Unfortunately, misinterpretation, in addition to gaps in the guideline, has led to unintended adverse consequences. Our report documented widespread misinterpretation of the CDC Guideline — specifically, the recommendation regarding the 90 morphine milligram equivalents (MME) dose,” the report found.

“Educating stakeholders about the intent and optimal application of this guideline and re-emphasis of its core beneficial aspects are essential. Instances have been reported where the CDC Guideline was misapplied to the palliative care and cancer populations with pain and to providers who care for these patient populations.”

The task force called for a more “even-handed approach” to opioid prescriptions that allows doctors to use their own clinical judgement on how to treat patients.

“Various health insurance plans, retail pharmacies, and local and state governments are implementing the CDC Guideline as policy, limiting the number of days a patient can receive prescription opioids even when the seriousness of the injury or surgery may require opioids for adequate pain management for a longer period. A more even-handed approach would balance addressing opioid overuse with the need to protect the patient-provider relationship by preserving access to medically necessary drug regimens and reducing the potential for unintended consequences,” the task force said.

That kind of thinking is heresy to anti-opioid crusaders and politicians who consider the CDC guideline a cornerstone of the government’s war on drugs. Even before the task force report was finalized, 39 state and territory attorney generals wrote a letter of protest.   

“As a matter of public safety, there is simply no justification to move away from the CDC Guideline to encourage more liberal use of an ineffective treatment that causes nearly 50,000 deaths annually,” the letter warns. “It is incomprehensible that officials would consider moving away from key components of the CDC Guideline.”

Critics have also claimed that some task force members have a conflict-of-interest because of their financial ties to pharmaceutical companies. Oregon Sen. Ron Wyden (D) — who has received millions of dollars in campaign donations from healthcare companies and insurers — recently told Mother Jones that the task force was “being used as part of the industry’s broader effort to water down the CDC’s recommendations on opioid prescribing.”

The 29 members who served on the task force included representatives from the FDA, CDC, VA and Office of National Drug Control Policy; as well as academic and medical experts in pain management, addiction treatment, pharmacy, oncology, psychiatry and interventional medicine. There was only one patient advocate, Cindy Steinberg of the U.S. Pain Foundation.

Interestingly, Harold Tu, MD, the lone dentist on the panel, is the father-in-law of Andrew Kolodny, MD, the founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group that played a key role in drafting the CDC guideline. Tu voted in favor of the task force’s final report.

The report’s recommendations are voluntary and not binding on the Department of Health and Human Services or anyone else. The task force was created in 2016 by the Comprehensive Addiction and Recovery Act to “determine whether there are gaps in or inconsistencies between best practices for pain management.”

Those gaps have been identified. Whether anyone will get to work and fill them is unclear.

“I think the task force provided a very good analysis of the problem with recommendations that if implemented should help millions of Americans with pain and reduce the problem with opioids,” says Lynn Webster, MD, past president of the American Academy of Pain Medicine and a PNN columnist.

“My concern is that there doesn't appear to be any teeth to the recommendations. I would like to have seen some specifics but that may have been too much to expect at this stage.”

Mindfulness Is More Than Yoga

Barby Ingle, PNN Columnist

For years I’ve used mindfulness meditation techniques to help with my chronic pain. So imagine my surprise last week as I was watching the Pain Management Best Practices Inter-Agency Task Force meeting and a practitioner on the panel said yoga and mindfulness are essentially the same thing.

I’ve never done yoga as part of my mindfulness meditation. But it made me start to wonder. Have I been doing mindfulness wrong for years?

A quick Google search showed me there are more than 25 mindfulness activities. Yoga was one of the items on the list, but not everyone doing yoga is doing it for mindfulness. Most use it for physical exercise.

Another practitioner on the task force said that mindfulness is not a treatment by itself and that it is typically done in conjunction with other modalities. I totally agree. There are many group and individual activities that use mindfulness to reduce stress, anxiety, depression and pain.

Mindfulness is just one form of self-care that I use do to help manage the symptoms of living with chronic conditions. By itself, mindfulness is not enough to sustain me, but in conjunction with other treatments I find it helpful.  

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I personally like individual mindfulness activities. Some of the activities are really short and some take up to an hour. Depending on what I need, I choose one that best suites me in the moment. Some of the activities I use for improving my life include virtual reality, self-compassion, reviewing my "I Am" list, meditation, 5 senses exercise, breathing exercises, music therapy and aroma therapy.

If you have trouble practicing mindfulness alone, one of the group activities is known as the FAKE plan, which involves about 8 members meeting for 2 hours every week for 12 weeks. The first portion of each session is devoted to a short mindfulness exercise and discussion, and each week is dedicated to a specific type of mindfulness exercise.

This is great for patients with social anxiety disorder but can also be helpful for others who want to work on their social skills through group mindfulness activities.  

Another mindfulness exercise that I found in my Google search (but have not yet tried) involves staring at a leaf for 5 minutes. A leaf is like a fingerprint or snowflake -- no two are the same. You can focus on the leaf’s colors, shape, texture and patterns. This type of activity brings you into the present and helps align your thoughts.

When I am not able to perform the physical or cognitive tasks I want to because of physical pain, I can get situational depression. For me, this is the best time to use my mindfulness activities. One study identified three ways mindfulness helps when you are depressed:

1.  Mindfulness helps people learn to be present in the moment, take stock of their thoughts and feelings, and choose an appropriate response rather than get caught up in negative emotions.

2.  Mindfulness teaches people that it’s okay to say “no” to others, which helps them balance their own lives and enhance self-confidence.

3.  Mindfulness allows people to be present with others, making them more attentive to their relationships, aware of their communication problems and more effective in relating to others.

These are important tools that can help chronic pain patients better manage their lives. Mindfulness activities help clear your mind of worry about the past or future and allow you to focus on the present.

Whether you are using mindfulness for anger, depression, chronic pain, anxiety or just for overall mental health -- it is important to keep an open mind. I know that is easier said than done when you are in severe pain. But the more you practice mindfulness the easier and more useful it becomes.

Can mindfulness cure you? No. Its purpose is to relax and help put life into perspective. If you are angry and distressed, that’s okay. I go there too sometimes. I use mindfulness to live in the moment and manage my emotions so that I am better able to manage my physical pain.

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Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain FoundationShe is also a motivational speaker and best-selling author on pain topics. More information about Barby can be found at her website. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.