EXECUTIVE SUMMARY Pain management is a complex, multidisciplinary field consisting of a variety of syndromes present in both the acute and chronic phases. In recent years, a dramatic increase in deaths from opioid overdose and other harms related to prescribing opioids for pain management has led clinical experts and policy analysts to acknowledge the need to examine clinical practices in pain management. Factors related to provider and patient education, risk stratification, service delivery coverage, and increasing stigma have further complicated the use of opioids for the treatment of pain and imposed challenges upon clinical management of acute and chronic pain. The Comprehensive Addiction and Recovery Act (CARA) calls for a coordinated response, including the establishment of an interagency task force to: (1) identify best practices for chronic and acute pain management and the prescription of pain medication (2) identify gaps and inconsistencies in current practices and (3) identify ways to best disseminate this information.
This Environmental Scan (ES) Report informs the Pain Management Task Force (PMTF) established by CARA and provides a brief overview of many clinical best practices and guidelines (CBPs), including those developed by medical associations and federal, state, and local government organizations for management of acute and chronic pain. The ES Report reviews pain management treatment approaches and provides the PMTF with a basis by which to address questions specified in part by CARA legislation. An initial set of questions for PMTF to consider include:
1. What are existing clinical best practices for management of acute and chronic pain developed by medical professional associations and the federal, state, and local governments?
2. What are existing knowledge gaps and inconsistencies across identified clinical best practices?
3. How do existing clinical best practices inform guidance on specific topics specified by the CARA language, including:
a) Pharmacological, non-pharmacological, and medical device alternatives to opioids to reduce opioid monotherapy in appropriate cases
b) Optimizing treatments based on differences within and between classes of opioids
c) Opioids with abuse deterrent technology d) Management of high-risk populations who receive opioids in the course of medical care, other than for pain management
4. How do non-clinical (i.e., policy-related) best practices advance and support best practices for management of acute and chronic pain? The ES Report identifies 38 CBPs, which include clinical recommendations among biopsychosocial and multidisciplinary approaches to pain management, including medication; physical therapy; psychological approaches; surgical and minimally invasive procedures; and complementary and alternative medicine (Question 1).
The ES Report describes CBPs relevant to pain management topics that can inform the existence of gaps or inconsistencies across best practices (Question 2), including four topics specified by CARA legislation. First, CBPs recommend multiple pharmacological and non-pharmacological alternatives (including medical devices, as well as complementary and alternative medicine approaches) to opioids (Question 3a). Second, CBPs do not make definitive recommendations about optimizing treatments based on differences within and between classes of opioids (Question 3b). Third, CBPs suggest that abuse deterrent technologies can be partially effective in the prevention of opioid abuse or misuse and should be used as part of a multifaceted-approach (Question 3c). Fourth, CBPs provide recommendations for management of high-risk populations, including prioritization of non-opioid interventions, consideration of abuse deterrent technology, medication-assisted treatment, provision of naloxone, and prioritization of nonpharmacological treatments (Question 3d). Finally, policy best practices facilitate the execution of CBPs and support other areas of pain management, including risk assessment and mitigation; patient education; provider education; access to care; medication-assisted treatment; provision of naloxone; parity laws; fentanyl detection; and stigma (Question 4). Further analysis of best practices identified by the ES or by the PMTF during future working group discussion may reveal gaps and inconsistencies that could inform development of more effective best practices for providers and policy makers.