Expert consensus on how to help patients with chronic pain get adequate care and coverage

The pendulum of opioid prescribing for pain has swung sharply in the last decade, as the epidemic of opioid overuse, addiction and overdose led policymakers and health care providers to ratchet back on the prescriptions patients receive.

But for about 5 million Americans who have taken prescription opioids for years to address their chronic pain, that pendulum swing has led to trouble getting refills, finding new providers when their former ones retire or relocate, or getting access to multimodal pain care that goes beyond pills.

In a new paper in the Journal of Pain Research, researchers from the University of Michigan describe the consensus of a wide range of experts about how to help patients with chronic pain get adequate pain care, and coverage for the cost of that care.

Specifically, the experts call for restructuring the insurance models under which health care providers get reimbursed for caring for people with chronic pain, enhancing education of health care providers in chronic pain care as well as identifying and treating opioid use disorder, and addressing racial inequities in care which are often rooted in stigma around pain and opioid use.

The experts, who came from many fields and many areas of Michigan, reviewed research on the issue and brought their own experience to a deliberative process known as a modified Delphi panel.

This allowed them to come to consensus on the most-needed and most-achievable changes, says study senior author Pooja Lagisetty, M.D., M.S., an assistant professor of internal medicine at Michigan Medicine, U-M's academic medical center, and the VA Ann Arbor Healthcare System.

In addition to the new paper, Lagisetty was recently interviewed about current issues in opioids and care for chronic pain and opioid use disorder for the Michigan Medicine research podcast The Fundamentals.

She, and the experts involved in the newly published paper, emphasize the importance of helping patients who have taken opioids for long periods of time get access to the gold-standard for chronic pain care.

Called multi-modal pain care, it involves not just oral pain medications but physical therapy, cognitive behavioral therapy, injected pain therapies and integrative medicine techniques including acupuncture and chiropractic care.

This requires both training and payment for the multiple types of health care professionals – physicians, nurse practitioners, physician assistants, psychologists, physical therapists, social workers and others – who can team up to provide such care.

"In order to encourage more clinics to offer multimodal pain care and increase access for patients who currently don't receive it, insurance companies and government health coverage programs such as Medicaid need to change how they pay for it," says Lagisetty. "We are starting to see some change, most notably at the VA and in insurance coverage of physical therapy, but more is needed in order for patients and providers to have time to develop individualized approaches, overcome stigma around providing opioid-related care, and for clinics to begin offering non-medication services."

Lagisetty notes that the new physician payment rule proposed for Medicare appears to pave the way for reimbursement for more comprehensive pain management care. But increasing access also requires training more providers in how to provide such care effectively.

Such care is in line with the opioid-related guidelines released last fall by the Centers for Disease Control and Prevention, which emphasize patient-centered care and an individualized, rather than broadly mandated, approach to prescribing opioids to patients.

The prior CDC guidelines were issued in 2016 in reaction to the role of prescription opioids in fueling addiction and overdose. Although intended as guidance rather than rules, they became the basis for policies and clinical practices that inadvertently closed doors to care for chronic pain patients, Lagisetty notes.

Without access to care and medication, patients may seek prescription and non-prescription opioids through unauthorized channels, leading to worsened risks of addiction, overdose and mental health, she adds. The lack of availability of care for opioid use disorder, which traces its roots to stigma and administrative hurdles, makes the issue worse, she says.

In addition to Lagisetty, the study's authors include Adrianne Kehne of the VA Center for Clinical Management Research, of which Lagisetty is a member, and several U-M faculty members who like Lagisetty are members of the U-M Institute for Healthcare Policy and Innovation: Steven J Bernstein, M.D., M.P.H., Mark C Bicket, M.D., Ph.D., and Amy Bohnert, Ph.D., as well as Erin Fanning Madden of Wayne State University, and U-M's Jennifer Thomas and Victoria Powell, M.D.

The expert consensus process was funded by the Michigan Health Endowment Fund, the National Institute on Drug Abuse (DA047475) and the National Institute on Aging (AG062043).

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