American College of Clinical Pharmacy
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ACCP Report - April 2019

ACCP Comments on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations


The Comprehensive Addiction and Recovery Act (CARA) of 2016 is a landmark piece of legislation authorizing substantial federal funding to address the prescription opioid abuse and heroin use crisis, including the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those practices.

The Task Force recently released a draft report describing the preliminary recommendations that will be finalized and submitted to Congress in 2019 after a 90-day public comment period. The preliminary report includes a call for input and comment from stakeholders on responses to some of the initial key concepts:

  • Balanced pain management should be based on a biopsychosocial model of care.
  • Individualized, patient-centered care is vital to addressing the public health pain crisis.
  • Better and safer opioid stewardship must be ensured through risk assessments that are based on the patient’s medical, social, and family history to facilitate safe and appropriate prescribing.
    • This will be a multidisciplinary approach to chronic pain that focuses on the patient’s medical condition, comorbidities, and various aspects of care including medications, restorative movement therapies, interventional procedures, complementary and integrative health, and behavioral health/psychological interventions.
  • A multimodal approach to acute pain should be used in the surgical, injury, burn, and trauma settings.
  • Perioperative surgical home and acute pain guidelines should be established to provide a framework for improved patient experience and outcomes.
  • Drug shortages that may affect acute and chronic pain care should be addressed.
  • Access to care is vital through improved health care coverage for various treatment modalities and an enlarged workforce of pain specialists and behavioral health clinicians to help guide and support appropriately trained primary care clinicians.
  • Empathy and a nonjudgmental approach are important to improve treatment and outcomes, given that stigma is a major barrier to treatment.
  • Education through societal awareness as well as provider education and training and patient education are needed to understand choices and promote therapeutic alliances between patients and providers.
  • Research is required to develop a better understanding of the mechanisms of pain, preventive measures, use of innovative medical devices and medications to prevent the acute-to-chronic pain transition, and methods to improve outcomes of chronic pain conditions.
  • Special populations should be highlighted, including children, women, older adults, American Indians/Alaskan Natives, and active-duty soldiers/veterans.

ACCP submitted comments in response to the call for input that stated the College’s belief that medication optimization is key to a comprehensive patient-centered approach to managing pain and other chronic or contributing medical comorbidities and that acute and chronic pain management requires an individualized, patient-centered approach.

More specifically, the comments included the following key recommendations:

  • ACCP asserts that clinical pharmacists are essential team members in the multidisciplinary approach to chronic pain that focuses on the patient’s medical condition, comorbidities, and medication management services, including medication-assisted treatment (MAT) services for those with a dual diagnosis of chronic pain and opioid use disorder.
  • ACCP recommends including pharmacy postgraduate programs in addition to graduate medical residency positions in pain specialties. Currently, there are only 25 accredited residency programs in pain management and palliative care pharmacy practice.
  • ACCP supports improved access to care through an enlarged workforce of pain specialists and behavioral health clinicians to help guide and support appropriately trained primary care clinicians, with clinical pharmacists providing CMM services in primary care practices. ACCP also supports educational efforts, including provider education and training, and promoting therapeutic alliances between patients and providers, and recommends that pharmacy residencies be expanded and included in workforce considerations.
  • ACCP supports innovative solutions to pain management such as telemedicine as part of the overall approach to pain management. ACCP encourages further incorporation of pharmacists into innovative practices such as Project ECHO and the hub-and-spoke model that can increase the workforce’s ability to provide best-practice comprehensive and specialty care.
  • ACCP recommends a comprehensive, team-based approach to managing chronic pain together with other medical comorbidities and a chronic disease management model that includes CMM services and aligns with value-based payment models.
  • ACCP supports research of methods to improve the outcomes of chronic pain conditions.
  • ACCP recommends the inclusion of research in practice advancement models across the disciplines in health care.

Click here to read ACCP’s comments in full.

Next Steps

Researchers at the Massachusetts General Hospital Institute for Technology Assessment estimate that restricting access to prescription opioids will only minimally affect the opioid overdose epidemic – a public health crisis that they project will only increase.1 In partnering with CSOO and ASAM, ACCP adds the voice and resources of clinical pharmacy to the voice and resources of those working to increase access to comprehensive, evidence-based outpatient treatment for Medicare beneficiaries with opioid use disorders; expand programs to treat substance use disorders, including MAT services; and expand grants for states and localities to improve their prescription drug-monitoring programs, collect public health data, implement other evidence-based prevention strategies, encourage data sharing between states, and support other prevention and research activities related to controlled substances, including education and awareness efforts.

References:

  1. American College of Clinical Pharmacy (ACCP). Statement to the United States Senate Committee on Finance in Response to the Request for Feedback on How to Improve Medicare, Medicaid and Human Services Programs Responses to the Opioid Epidemic. February 16, 2018. Available at www.accp.com/docs/govt/ACCP_Opioid_Epidemic_Statement_2018.pdf.