Chronic Pain: NPS and the CDC Guidelines Trending on Social Media

Chronic pain topics trending on social media have increased with the release of the National Pain Strategy (NPS) and the CDC Guidelines for Prescribing Opioids. Having submitted comments on both drafts, I felt it was time to express my personal opinions. There are vast differences between the two, even though the “CDC Guidelines” are specifically mentioned at the conclusion of the NPS report.

CDC Opioid Checklist: The good, the bad, and the ugly 

Overall, the checklist is not difficult to understand and physicians will be more likely to use it. Where I do not comment, assume it to mean I don’t see any reason to mention it.

Good Stuff:

·        “For primary care providers treating adults.” - Primary care physicians need guidelines by government agencies so they do not fear retaliation by the DEA. Not all patients living with persistent pain require supervision by a pain specialist; in fact, there aren’t enough pain physicians to meet the needs of over 100 million Americans living with chronic pain.

·        “Known risk factors” – Important assessment.

·        “Prescription drug monitoring program”  (eleven states do not have a PDMP) – You can read what I think about medication safety on my website. PDMPs are good for identifying signs of drug diversion or abuse, which protects responsible people, but will physicians who treat patients with conditions that cause chronic pain, i.e., pain physicians or rheumatologists be singled out? And, how will this affect patient care in states without a PDMP?

·        “Behavioral treatment” – This piece is often difficult for physicians to discuss with their patient’s, and vice versa. However, there is evidence that shows our behavioral response to pain makes a difference in our ability to cope with the fall of of living with chronic pain, and how we respond to it mentally and emotionally can affect our pain intensity. (This does not mean it treats the pain source directly, however.)

·         “Schedule initial reassessment within 1– 4 weeks.” – This should be done any time a new medication is started, including non-opioids that affect the central nervous system.

·        “Assessing pain and function using PEG scale” – This one gets a mixed review. Relieving pain, decreasing the intensity to improve quality of life is the reason we seek pain care. However, quality of life should be assessed according to what that means for each individual patient. For instance, a diseased spine or joint is not going to function better despite pain relief. Q1 is difficult because it relates to an acute pain scale, which is not helpful for assessing chronic pain, especially in a person with more than one pain condition. Q2 reverts back to my comments on changing behaviors. Enjoyment of life is not affected by opioids, it is affected by developing healthy coping skills as is the truth for any chronic illness. Enjoyment of life fluctuates for everyone.  Q3 Improving endurance, i.e. activity, cannot be achieved without therapies that are often capped by Medicare and is not based on patient outcome. And, easing pain will not necessarily result in increased activity. Overall, asking a patient to make their own assessments is important, but placing an arbitrary number (30% improvement) is punitive. Many factors, life situations, can cause the numbers to fluctuate. One cannot assume status quo for chronic pain anymore than they can assume blood sugars will remain constant in treatment of diabetes.

Bad Stuff

·        “Benefits of long-term opioid therapy for chronic pain not well supported by evidence.” – Describe evidence? Anecdotal reports from physicians who specialize in pain medicine are evidence (but they were not represented in the “Core Group” of experts). If they are referring to research, there is no evidence to suggest opioids don’t work for long-term pain care.

·        “Schedule reassessment at regular intervals (≤ 3 months)” – This guideline is not appropriate for patients who do not need advanced pain care. Patients who have been on the same opioid dose for years do not require such close observation. Many patients, particularly the elderly, do not have the ability to see the doctor this frequently, nor is the physician available. To put an absolute time interval (without cause) puts an unnecessary burden on the physician, patient, and insurance, including Medicare, and drives up healthcare costs. This is a total disregard for common sense.

·        “Urine drug screens.” I am not against them when there are signs of abuse. (Perhaps the checklist should include assessment of those behaviors.) However, using drug screens to assess risk without probable cause is offensive for several reasons: they are accusatory (guiltily until proven innocent), they are humiliating, they are not consistently accurate, and they are not always covered by insurance, which is discriminatory against folks who can’t pay. Innocent people are being tortured by inaccurate results, while drug testing companies are making a killing, sometimes literally.

The Ugly

·        “NON-OPIOID THERAPIES Use alone or combined with opioids, as indicated:” – Suggesting long-term use of NSAIDs is not safe, and there is evidence to suggest this. Antidepressantsare not without consequences; they have many drug-to-drug interactions and can lead to suicidal thoughts, they are not always a safer choice. Anticonvulsantsare also abused because of euphoric effects and can have serious side effects like antidepressants. Non-opioid treatments should be considered, but the effects of alternate drugs should not be undermined.

·        “Calculate opioid dosage morphine milligram equivalent (MME).” Every patient is different. It is common sense to taper any drug or treatment to effect, but this particular issue could put a prescribing physician at risk of litigation.  (See Dr. Fudin's opinions.)

The National Pain Strategy (NPS)

“National Pain Strategy outlines actions for improving pain care in America

Plan seeks to reduce the burden and prevalence of pain and 

to improve the treatment of pain”

There are many things I agree with, some that I can tolerate, and others that I felt needed attention. The NPS did have representation by advocates during its draft, and we have all been waiting for it to be released. And, so it has been. You can see and overview and download the National Pain Strategy here.   

“The Strategy provides opportunities for reducing the need for and over-reliance on prescription opioid medications;” this statement disturbs me. I believe the only way we can reduce the need for pain relief is to find a cure for scleroderma, complex regional pain syndrome, the effects of aging on the body, arthritis, fibromyalgia, EDS, myofascial pain syndrome, the centralization of pain, etc. Relieving pain is instinctive to all animals, including humans.

Not including all the stakeholders in the drafting of the CDC guidelines has many advocates and advocacy groups incensed, and rightly so. Public notice of the guidelines was made public for only 3 days. Only after being caught, did they allow our voice. But, despite pleas made by people far better equipped and knowledgeable (and unlike me, able to retain what they read), the CDC published them anyway. The total disregard for our government process - by, with, and for the people - is deplorable.

The CDC guidelines could have been done much better and would have been better received if our voices had been heard. And, it bothers me that the NPS overview ends with this statement, The goals of the National Pain Strategy can be achieved through a broad effort in which better pain care is provided, along with safer prescribing practices, such as those recommended in the recently released CDC Guideline for Prescribing Opioids for Chronic Pain. I doubt many of those who helped draft the NPS were aware of these guidelines being drafted when they participated in the drafting of the NPS. Some of those same people are among those who tried to hold the CDC accountable for their lack of transparency. (Read about it in The Guardian.) The CDC Opioid Prescribing Guidelines are not all bad, but they are written with a discriminatory tone, which is counter-productive to the Institute of Medicine’s report, Relieving Pain in America, available from my website here.

To me, it is more of the same and that’s really is a shame. Persistent untreated pain has biological consequences that are seldom considered, and certainly not here. A great opportunity has been squandered by lack of corroboration, something I value.

You can read my comments to the NPS and the CDC guidelines:

• Make a Public Comment on theNational Pain Strategy
• The CDC Opioid Guidelines:Exercise Your Right to Be Heard

Other blogs of interest:

• Healing What Hurts: The Politics of Pain: A Symposium Overview by Celeste Cooper
• The symposium "Patients as Teachers," "Clinicians as Learners," a synopsis by Celeste Cooper 
• A Patient Powered Network: Change Agents for Relieving Pain in America (About our group coming together to change the way pain is perceived, judged and treated.)

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"Adversity is only an obstacle if we fail to see opportunity."  

Celeste Cooper, RN

Author—Patient—Health Central Chronic Pain Pro —Advocate

Celeste’s Website: http://CelesteCooper.com

Learn more about what you can do to help your body function to its potential in the books you can find here on Celeste's  blog. Subscribe to posts by using the information in the upper right hand corner or use the share buttons to share with others.

All answers and blogs are based on the author's opinions and writing and are not meant to replace medical advice.  

Make a Public Comment on the National Pain Strategy by Celeste Cooper

The National Pain Strategy is out. 

You can view it and download it here. 

Public comments on the draft National Pain Strategy must be received no later than 5 p.m. EST on May 20, 2015. Written comments sent electronically are preferred and may be addressed to NPSPublicComments@NIH.gov

Following is mine.

To whom it may concern:

I agree that collaboration between primary and pain specialists is helpful in some cases, though I do not believe it is mandatory, and this is why.

• Many pain specialists are only interested in interventional care.
• Monthly visits for the pain patient who uses a non-escalated dose of opioids over a period of years, for instance, is time consuming and costly to the patient and society.
• Forcing patients into a chronic pain program that have not had any red flags, are not a safety risk, could create perceived stigma where there was none.
• To think that a primary physician cannot complete continuing education courses for management of mild to moderate chronic pain is ridiculous.
• Primary physicians are on the front lines. They will be held accountable for prevention strategies, but they aren’t able to make assessments for treating pain? This seems like tying their hands behind their backs. Board certified family physicians should not be segregated from treating uncomplicated chronic pain independently. Who is better trained in meeting the biopsychosocial needs of a patient?
• Certainly, complicated chronic pain should be under the supervision of a pain specialist, however not all patients meet this criteria, and not all pain specialists take a biopsychosocial approach. It would be interesting to have the data on this and I am grateful you are doing just that.

What I like as an RN and a Chronic Pain Patient

• Core competency in treating complicated chronic pain.
• Addressing the stigma of chronic pain.
• A biopsychosocial model.
• Collecting data that will improve outcome based treatment.
• Recognition of the need for programs that address patients as a whole.
• Studying chronic pain as a disease.
• Advocating for complimentary treatments that work, with the goal of making them accessible to all patient regardless of ability to pay.

Playing Devil’s Advocate

Standardizing electronic records in a free corporate society may not be possible. This should have been planned out before it was ever initiated. I have physician family members who tell me EMRs will not be practical as long as there are so many different computer programs.

Have you ever taken any of the alternative drugs offered? Why aren’t we equally concerned about the abuse of drugs like Neurontin® or Lyrica®? There was not one mention of these drugs in this report. Isn’t focusing only on opioids stigmatizing?

Will all insurance companies be willing to pay for integrative treatments? If not, which is most likely, doesn’t this mean those of us without deep pockets will not be able to afford the complimentary care our physicians expect? It is difficult to get Medicare to pay for TENS units and supplies. But they will pay for interventional procedures, some that are costly to society and have not been proven to bring any lasting effects. How can we curtail spending if we put all pain care in the hands of already overloaded pain specialists?

How can we force private practice pain physicians to adhere to and develop a clinic that takes a biopsychosocial approach to treatment? Is this not a violation of free enterprise of our nation? Not that I don’t agree this is the right approach, but in practicum, is it possible?

How are we to stop the stigma associated with chronic pain if opioids are seen as bad? The patient’s who benefit from opioids, that do not require escalated doses of many years, and do not tolerate alternative drugs, like myself, are not identified in the data. Without this data, won’t chronic pain always have an associated stigma? The last data I saw was that 70% of patients using opioids would not abuse their medications. Can we expect future data on this?

How many overdoses occur from under-treatment of pain? Can we expect a comparative analysis? Why is opioid treatment for chronic pain left out of the conundrum of opioid statement? Isn’t this stigmatizing?

Despite best efforts, chronic pain will exist. When the patient does approach their pain in a biopsychosocial way (I write books on this and practice it), and their pain persists, will they feel inadequate, isolated, and depressed, all the things a multimodal approach is supposed to fix?

Conclusion

Looking at chronic pain as a public health issue is the right approach in my opinion. It will avail resources that wouldn't otherwise be accessible. The report is comprehensive, there will be roadblocks in implementing all the suggestions, but hopefully generations to come will benefit. As an educator, I was impressed on seeing short-term to long-term goals. This strategy provides a mechanism for reassessment and revision.

Chronic pain devastates the lives of people living with it. Patients did not ask to have injury, anatomical defects, or disease processes that create the chronic pain web of deceit. Acceptance is necessary for forward momentum, and that doesn't include just the patient, it also includes their provider, their families, their employers (if they are lucky enough to have one), their friends, and society in general.

Learn more about what you can do to help your body function to its potential in the books you can find here on Celeste's  blog. 

~ • ~ • ~ • ~ • ~ • ~

"Adversity is only an obstacle if we fail to see opportunity."  

Celeste Cooper, RN

Author—Patient—Health Central Chronic Pain Pro —Advocate—Sharecare Fibromyalgia Health Expert

Website: http://CelesteCooper.com

All answers and blogs are based on the author's opinions and writing and are not meant to replace medical advice.