The Department of Health and Human Services released Dec. 28 a long-awaited draft report on pain management best practices amid the nationwide opioids crisis.
The report, titled “Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations,” was headed up by Indian American physician Vanila Mathur Singh, who serves as chair of the Pain Management Best Practices InterAgency Task Force at the Department of Health and Human Services. Singh is the chief medical officer at the Health and Human Service’s Office of the Assistant Secretary for Health. She was appointed to the post in 2017 by former HHS Secretary Tom Price.
Singh told India-West she could not comment on the draft report, but described it as her “magnum opus,” which leans heavily on her 13 years of teaching anesthesiology, perioperative and pain medicine at Stanford University. In her practice as an anesthesiologist, Singh specializes in treating patients with complex chronic pain issues.
In a statement announcing the release of the draft report, Singh noted: “Chronic pain affects an estimated 50 million U.S. adults or 20 percent of the adult population. An estimated 19.6 million U.S. adults have experienced high-impact chronic pain, which the CDC defines as pain occurring and interfering with life or work activities most days.”
“This draft report offers a wide range of treatment modalities with a framework to allow for multidisciplinary, individualized patient-centered care.”
Significantly, the draft report — which is open for public comment for 90 days before it is finalized and submitted to Congress — suggests several alternatives to pain management that do not rely on the use of opioids.
In a talk Singh presented last November at the Texas Pain Society’s 10th annual scientific meeting, the Stanford physician noted the wave of opioid-related deaths: over the past two decades, 183,000 people have died from the misuse of opioids.
For every one death, noted Singh, 273 people report having misused opioids, and 41 people report having a substance abuse disorder related to prescription opioids.
The National Survey on Drug Use and Health reports that approximately 11.4 million individuals misused opioids in 2017; of those, 11.1 million were misusing prescription pain relievers.
A rising number of suicides were attributed to chronic pain and the misuse of opioids.
Synthetic opioids other than methadone, which include both prescription and illicit fentanyl, are now the leading opioids involved in overdose deaths in the U.S., noted the report.
Dispelling the popular myth of junkies using opioids to get high, Singh noted that the overwhelming majority of those surveyed — more than 62 percent — said they misused opioids to relieve physical pain. Tinier percentages misused opioids to help with sleep, to relieve tension, or help with emotions.
The draft report recommends several non-opioid approaches to treatment of chronic pain. The use of opioids to combat acute pain post-surgery or trauma should be for the shortest time possible, stated the report, noting that 6 percent of people who are given opioids post-surgery become habitual, dependent users. The report also questioned the effectiveness of opioids used for more than three months in combating chronic pain.
Singh and her co-authors recommended various non-opioid medications, ultrasound-guided nerve blocks, analgesia techniques, including lidocaine and ketamine infusions, and psychological and integrative therapies.
Non-opioid medications that are commonly used include acetaminophen, nonsteroidal anti-inflammatory drugs, antidepressants, anticonvulsants, musculoskeletal agents, and anxiolytics.
The report recommended an individualized, patient-centric approach to pain management, noting that one therapy does not work for all patients.
The report also delves into access to pain care, education and training, including risk assessment. It also provides specific recommendations for special populations, including older adults, women, ethnic and racial minorities, military members and veterans.
“Socioeconomic and cultural barriers may impede patient access to effective multidisciplinary care,” noted the report. “There is evidence of racial and ethnic disparities in pain treatment and treatment outcomes in the United States, yet few interventions have been designed to address these disparities.”
Lower quality pain care may be related to many factors, including barriers to accessing health care, lack of insurance, discrimination, lack of a primary care physician, lack of child care, lower likelihood to be screened or receive treatment, and environmental barriers that impede self-management, noted the report.
The American Society of Anesthesiologists released a statement Jan. 2 applauding Singh and HHS for releasing the report, and noted that many of the recommendations align with solutions presented and advocated by ASA.
“By utilizing opioid-sparing techniques, physician anesthesiologists can impact the number of opioids prescribed to patients and consequently the number of unused opioids in families’ homes following surgery,” said ASA president Linda Mason.
“This report represents a far-reaching road map for advancing safe, patient-centered best practices in acute and chronic pain management,” said Asokomar Buvanendran, M.D., chair of ASA’s Committee on Pain Medicine.
The full text of the draft report can be read here: https://bit.ly/2F9Odvh.