Federal recommendations issued in May call for an individualized, multidisciplinary approach to treating people’s pain—whether it’s acute pain from surgery, burns and injuries, or chronic pain associated with trauma or conditions such as sickle cell disease, arthritis or fibromyalgia.
The U.S. Department of Health and Human Services (HHS) convened a 29-member Pain Management Best Practices Inter-Agency Task Force in response to the nation’s opioid crisis. The group recommends a biopsychosocial approach in which health-care providers assess a patient’s entire context to develop a treatment plan that minimizes the risk of opioid misuse.
“The role of psychologists in this is profound, vital and underutilized,” says task force member Halena M. Gazelka, MD, director of the Mayo Clinic’s inpatient pain services.
APA supports this “whole person” approach to care. In June, APA CEO Arthur C. Evans Jr., PhD, testified before Congress about the critical role that evidence-based psychological services can play in more effective pain management care and reduced exposure to opioids.
A range of treatments
The task force report advises that pain management plans should often include more than one type of treatment, including physical therapy, opioid and non-opioid medications, nerve blocks, minimally invasive procedures and behavioral interventions.
“The behavioral health section of the report outlines promising and evidence-based psychological interventions for pain all in one place, and that’s pretty noteworthy,” says Cecelia Spitznas, PhD, one of two psychologists who served on the task force and senior science policy adviser at the Office of National Drug Control Policy.
Among the treatments cited are behavioral therapy, cognitive-behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and emotional awareness and expression therapy.
The recommendations reflect a growing awareness that pain includes complex biological, cognitive, emotional, behavioral and social factors, says task force member Mary W. Meagher, PhD, a professor in Texas A&M University’s department of psychological and brain sciences.
Instead of measuring pain on a simple numerical scale, for example, the report advocates for evaluating how pain interferes with daily activities and a person’s quality of life. “Those are domains where psychological interventions have been demonstrated to show great effectiveness,” says Meagher. As examples, the report cites brief presurgical interventions that reduced patients’ needs for opioids after surgery, including a study led by Baylor College of Medicine psychologist Lilian Dindo, PhD, that used acceptance and commitment therapy with veteransopens in new window having orthopedic surgery (The Journal of Pain, Vol. 19, No. 10, 2018), and another study led by Stanford University psychologist Beth Darnall, PhD, that used a single, two-hour pain control class to help breast cancer surgery patientsopens in new window (Journal of Pain Research, Vol. 7, 2014). (Read more about managing pain without opioids in the June Monitor.)
A call to action
The task force was convened by HHS in conjunction with the Department of Defense, Department of Veterans Affairs and Office of National Drug Control Policy. It was created under the Comprehensive Addiction and Recovery Act of 2016, a law to increase prevention programs and treatment for opioid use disorder.
“This is essentially another call to action, an opportunity to better integrate psychology so that pain is better treated nationally,” says Darnall, who wrote the APA book “Psychological Treatments for Patients With Chronic Pain” (available at www.apa.org/pubs/books/4317497).
Indeed, the report joins a growing chorus of voices calling for more integrative approaches to pain management. The 2016 National Pain Strategy included similar recommendations, and in June the American Medical Association passed new policies that include advocating for increased access to non-opioid treatments, including behavioral therapies.
The momentum is driven by growing recognition of the personal and economic impact of chronic pain and the nation’s opioid crisis. An estimated 50 million adults have chronic daily pain, and acute and chronic pain cost the United States an estimated $560 billion to $635 billion annually. “That’s more than the combined costs of treating heart disease, stroke and diabetes,” notes Meagher.
Challenges
Achieving better patient-centered pain management will require addressing several challenges, the task force report says. These include:
More basic and translational research, including efforts to understand the molecular and cellular mechanisms of pain and the genetics of pain.
Gaps and inconsistencies in best practices. The report calls for developing clinical best practices tailored to special populations, such as veterans and older adults, as well as to specific conditions. Some policymakers and physicians have misinterpreted the Centers for Disease Control and Prevention’s 2016 opioid prescribing guidelines, preventing some patients with severe pain from receiving adequate care, the report notes. It explains that while reducing opioid misuse is important, opioids should remain an option as long as the benefits outweigh the risks.
Reimbursement. Many insurance providers reimburse for non-opioid treatments at lower rates. Instead, reimbursement could incentivize providers to take a broader, integrative approach. Meagher, Spitznas and other task force members met with the Centers for Medicare and Medicaid Services this summer on a review of Medicare and Medicaid coverage policies related to the opioid epidemic.
Growing awareness and expertise. Many patients have limited provider options, especially in rural areas. Physicians, dentists, psychologists and other health-care providers could use more education on the spectrum of pain management options. Also, few providers specialize in pain management. To address the shortage, Darnall encourages more psychologists to gain expertise in pain management and get involved with developing technology-driven interventions.
