Advancing the Practice of Pain Management Under the HHS Opioid Strategy

Over the past 15 years, communities across America have been devastated by increasing prescription and illicit opioid abuse, addiction, and overdose.

In 2016, 11 million Americans misused prescription opioids, nearly 1 million used heroin, and 2.1 million had an opioid use disorder due to prescription opioids or heroin. And every day, an estimated 90 Americans die from an opioid overdose—resulting in more than 300,000 deaths since 2000.  Meanwhile, an estimated 25 million Americans experience pain every day. For many of these individuals, this pain interferes with their physical and mental health, work productivity, and ability to engage in social activities.

The opioid crisis has a variety of causes. In many communities, it has been driven by both socioeconomic challenges and lack of attention to behavioral health issues. Research has also shown that the significant rise in prescribing of opioid pain medications that began in the mid to late 1990s has been a key factor in the increase in opioid use, abuse, overdose, and death.

Transforming how we treat pain and recalibrating the role opioid medications play in pain care are a critical part of achieving the goals of reducing opioid harms and improving the quality of life for patients living with pain.

Rethinking pain treatment is a critical piece of the five-point Opioid Strategy HHS unveiled in April 2017. The strategy aims to:

• Improve access to prevention, treatment, and recovery support services to prevent the health, social, and economic consequences associated with opioid addiction and to enable individuals to achieve long-term recovery;
• Target the availability and distribution of overdose-reversing drugs to ensure the provision of these drugs to people likely to experience or respond to an overdose, with a particular focus on targeting high-risk populations;
• Strengthen public health data reporting and collection to improve the timeliness and specificity of data and to inform a real-time public health response;
• Support cutting-edge research that advances our understanding of pain and addiction, leads to the development of new treatments, and identifies effective public health interventions to reduce opioid-related health harms; and
• Advance the practice of pain management to enable access to high-quality, evidence-based pain care that reduces the burden of pain for individuals, families, and society while also reducing the inappropriate use of opioids and opioid-related harms.

HHS is taking significant steps to implement the Opioid Strategy, including a long sought focus on advancing the practice of acute and chronic pain management. Our activities in this area fall into three categories: 1) Advancing national pain care policy; 2) Providing clinicians and patients with education and tools to improve pain care; and 3) Supporting cutting-edge research on pain.

Advancing National Pain Care Policy

National Pain Strategy Implementation

The National Pain Strategy outlines the federal government’s first coordinated plan to reduce the burden of chronic pain in the U.S. and provides a roadmap toward achieving a system of care in which all people receive high quality, evidence-based pain care.

The Strategy includes actions in six areas: 1) population research; 2) prevention and care; 3) disparities; 4) service delivery and payment; 5) professional education and training; and 6) public education and communication. As highlighted during a May 2017 public meeting, HHS and partner agencies and organizations are making significant progress in implementing the Strategy.

Pain Management Best Practice Inter-Agency Task Force

The creation of the Pain Management Best Practices Inter-Agency Task Force was announced by HHS in August 2017. The Task Force, mandated by the 2016 Comprehensive Addiction and Recovery Act, will include HHS, the Departments of Defense and Veterans Affairs, as well as the Office of National Drug Control Policy and various external pain stakeholders. The Pain Task Force will identify gaps or inconsistencies in pain management best practices, propose updates and recommendations to address identified gaps or inconsistencies and, as appropriate, submit updates to relevant federal agencies and the public.

Hospital Reimbursement and Patient Pain Management Experience

Health care providers have long expressed concern that scores related to pain management questions in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, tied to hospital reimbursement, could be leading to inappropriate prescribing of opioids.

In response to these concerns, starting October 1, 2017, the Centers for Medicare and Medicaid Services will no longer link the HCAHPS pain management scores to hospital payment under the Hospital Value-Based Purchasing program. This represents a significant step forward in aligning payment policy and clinical practice for opioid prescribing.

Providing Clinicians and Patients with Education and Tools to Improve Pain Care

Centers for Disease Control and Prevention Opioid Prescribing Guidelines and Tools

CDC’s Guideline for Prescribing Opioids for Chronic Pain was developed to help primary care doctors provide safer, more effective care for patients with chronic pain outside of active cancer, palliative, and end-of-life care. A number of Guideline resources have been developed for providers, including a series of interactive, online trainings and a mobile app that contains the Guideline recommendations, a morphine milligram equivalent calculator, and an interactive interviewing feature to help providers prescribe with confidence. CDC continues to engage with a broad range of stakeholders to support guideline implementation that meets the needs of patients and providers across many diverse care settings.

CDC Rx Awareness Campaign

In September 2017, CDC released its Rx Awareness communications campaign to increase awareness about the risks of prescription opioids and deter inappropriate use. The campaign features real-life accounts of individuals living in recovery and individuals who have lost someone to an overdose.

Food and Drug Administration Opioid Analgesic Risk Evaluation and Mitigation Strategy

FDA recently announced it is expanding its Extended-Release and Long-Acting Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) to include immediate-release opioid analgesics.

Given that approximately 90 percent of all opioid analgesic prescriptions are for immediate release products, this change represents a significant step forward. As part of the REMS, FDA developed a new “draft blueprint” for prescriber education, expanding its content to include the principles of pain management, including non-opioid medications and non-medication treatments for pain; how to assess, treat, and monitor patients when opioids are appropriate; and information on the basics of addiction medicine.

National Institutes of Health Centers of Excellence in Pain Education

NIH funds Centers of Excellence in Pain Education at 11 academic institutions in the U.S. The Centers act as hubs for the development, evaluation and distribution of pain curriculum resources for medical, dental, nursing, pharmacy, and other health professional schools to improve how healthcare professionals are taught about pain and its treatment.

Supporting Cutting-Edge Research

NIH Public-Private Partnership

With the goal of bringing scientific solutions to the opioid crisis, NIH is exploring ways to promote safe, effective and non-addictive strategies to manage pain as part of a broader public-private partnership aimed at halving the time needed to develop new therapeutics to help end the opioid crisis. To advance the efforts, since June 2017, NIH has held three seminal meetings with the pharmaceutical industry, researchers, and other experts in pain and addiction.

Interagency Pain Research Coordinating Committee

NIH, through the Interagency Pain Research Coordinating Committee, developed the Federal Pain Research Strategy, a long-term strategic plan to coordinate and advance pain research. The Strategy’s research priorities include prevention of acute and chronic pain, management of acute pain, transition from acute to chronic pain, and understanding the disparities that influence pain and pain management. The recently announced NIH-DoD-VA Pain Management Collaboratory is investing $81 million to implement cost-effective large-scale clinical research in military and veteran healthcare delivery organizations, focusing on non-medication approaches to pain care and other comorbid conditions, reflects progress in implementing the Strategy.

Research to Inform Clinical Practice

Many states, health systems, and healthcare professional organizations are implementing policies that reduce opioid prescribing and encourage non-opioid options, which will improve long-term pain treatment and outcomes. HHS agencies are funding research to evaluate the effectiveness of these policies, identify any unintended consequences, and disseminate information on what works. This research will help to ensure that policies are evidence-based and that patients are able to access the care they need.

Moving Forward

Significant efforts toward patient-centered solutions are being made each day across HHS with the goal of reducing opioid abuse, addiction, overdose, and deaths while addressing the challenges that exist in the lives of individuals living with chronic pain. HHS is committed to bringing the full extent of its expertise and resources to bear in this fight.

By working in partnership with our state, local, and nongovernmental partners to build collaborations, share best practices, increase awareness, expedite relevant research, and encourage innovation, we can turn the tide and restore the lives of the millions of Americans touched by the opioid crisis.