Beth Darnall, PhD
Professor of Anesthesiology, Perioperative and Pain Medicine
Director of Stanford Pain Relief Innovations Lab
Stanford University School of Medicine
Patients have spoken. Thousands of people living with pain responded to requests for information from the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) to understand issues around access to covered pain treatments. For the latter, the CDC solicited information and conducted interviews with patients and other stakeholders to integrate their perspectives into a forthcoming update to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.1 One output of these efforts was the 2022 CMS Chronic Pain Experience Journey which illustrates thematic content voiced by patients.
Issues displayed in the infographic illustrate the multitude of challenges patients face. The net result is that many patients are left to navigate their daily life circumstances while coordinating what care they can receive and managing a variety of care gaps with little or no support.
Persistent barriers to pain care can greatly compound pain and suffering. Proximity to healthcare centers, insurance issues, too few trained providers, and costs are just some of the issues that impede patients’ access to needed pain treatment. These issues are not new, and solutions are needed to address them issues connect patients to effective pain care.
• Scalable and home-based treatments. The 2016 Federal Pain Research Strategy and the 2019 HHS Pain Management Interagency Best Practices Task Force5 identified the need for scalable and accessible pain treatment options. Home-based, automated, online, and telehealth options offer treatment avenues that may support patients where they are, and thus better equalize access to pain treatment.
• Reimbursement. Improved reimbursement models are needed for telehealth and evidencebased automated treatments.
• Prior authorization red tape. Extensive prior authorization and repeated denials from insurance leave clinicians and patients with few feasible treatment options. Payors should be incentivized to support patient-centered pain care with early access to conservative treatments and a stepped-care approach that tracks with costs and treatment intensity.
• Addressing the unintended consequences of the CDC opioid guideline. The CDC documented the unintended consequences of the 2016 Opioid Prescribing Guideline: misapplication that included a regulatory climate of “legislated medicine” that punished clinicians who prescribed opioids and led to many patients losing access to medication they may have benefitted from. The CDC is soon to publish its update to the
2016 opioid prescribing guideline with language stating that the opioid doses discussed are meant to be a guide and not hard thresholds that would replace clinician decision-making around individual considerations. As history has shown that such clarifications are insufficient for curbing inappropriate state and federal legislative and regulatory behaviors, stronger actions are needed to protect patient-centered prescribing and thus the fraction of patients who require opioid analgesia. Such actions could include a CDC registry for public documentation of misapplications and a task force dedicated to addressing large-scale misapplications (e.g., state based prescribing laws, state medical board regulations, and policies and practices of the Drug Enforcement Agency). Specific to care gaps and the problems outlined in the CMS infographic, the CDC may anticipate misapplications of the forthcoming update to the opioid prescribing guideline. Out of an abundance of caution, the CDC could consider creating a system for public reporting to allow rapid corrections and impactful public and professional communications to ensure patient safety and minimize harm.
• Addressing stigma. The infographic included provider fear and providers opting out of caring for the person with pain. With repeated insurance denials and other issues, the increased provider burden of caring for people with pain may be actual or perceptual; in either case, it can contribute to stigma and further erode patient access to pain treatment. Stigma experienced by patients within a healthcare system can fracture their connection to their care and may impede them from even seeking care. Enhanced medical and provider education may address aspects of stigma and support good communication and functional patient-clinician relationships. Patientlevel interventions may support coping with stigma. Finally, systems operations improvements that reduce provider burdens may enhance engagement and ultimately patient receipt of care.
Federal Actions to Pave the Way
How can we better support patients with pain and the clinicians who treat them? A roadmap is needed, and the 2016 National Pain Strategy provided a blueprint for improving pain care systems nationally. The 2020 Best Practices Interagency Pain Management Task Force provided additional actionable recommendations.
• Congress. Congressional appropriations supported the HEAL initiative, which in part has led to funding for pain research. However, a gap analysis is needed in terms of the National Pain Strategy and the Best Practices Interagency Pain Management Task Force and required appropriations to urgently shore pain care gaps.
• CMS. CMS has several efforts underway, including improving fee schedules for pain management billing codes (see Federal Register here: https://public-inspection.federalregister.gov/2022-14562.pdf) and improved utilization of codes to increase access to non-pharmacologic pain treatments. CMS also notes that they are actively seeking collaboration with federal partners and are exploring opportunities to address issues identified and illustrated in the Chronic Pain Experience Journey Map.
Opioid litigation settlements are in excess of $26 billion. State allocations represent an opportunity to direct funds in needed ways to ensure patients have access to evidence-based, coordinated, and effective pain care for each individual.
Finally, only by keeping patients at the center of the conversation will problems be addressed effectively. Inclusion of patients on policy boards, state medical board committees, and meetings is needed to fully appreciate the patient perspective and to develop patient-centered policies and practices that meet their needs.