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Welcome to the Integrative Pain Care Policy Congress Blog!

Brought together by their collective agreement that comprehensive integrative pain management is the best approach to caring for people with pain, and that none of us can properly advance this kind of care alone, the Integrative Pain Care Policy Congress is made up of leaders from more than 50 organizations (and growing!) representing the full scope of licensed and certified health care providers, public and private payers, policy experts, and pain research and patient advocacy organizations.

Are you or your organization interested in joining the Policy Congress, or would you like to receive email updates when this blog is updated? Contact Amy Goldstein for more information.

 

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IPCPC Hosts Webinar with Drs. Vanila Singh and Shari Ling

Posted By Katie Duensing, Friday, December 7, 2018

On December 3, 2018, the Integrative Pain Care Policy Congress held a webinar with Dr. Vanila Singh, Chief Medical Officer for the Office of the Assistant Secretary for Health at HHS, and Dr. Shari Ling, Deputy Chief Medical Officer at the Centers for Medicare and Medicaid Services.

The purpose of this webinar was to hear an update from Dr. Singh on the HHS Pain Management Best Practices Inter-Agency Task Force and to facilitate discussion with Drs. Singh and Ling around Policy Congress action steps to ensure that our respective and collective efforts are aligned whenever possible in an effort to best improve access to Comprehensive Integrative Pain Management.

If you were unable to attend the live webinar, you may view a recording of the webinar here.

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Guest Post: Reduce care barriers for nonpharmacological pain management

Posted By Sherry McAllister, DC, Foundation for Chiropractic Progress, Monday, November 26, 2018

An unfortunate tendency of pain management is that patients seem to choose the least expensive, most readily available option, even if it is not the most effective or appropriate. Given this commonality, a new study and associated commentary published in JAMA Network Open present some troubling evidence concerning the U.S. pain and opioid epidemic.

The study, “Coverage of Nonpharmacologic Treatments for Low Back Pain Among U.S. Public and Private Insurers,” examines coverage policies across a nationally representative sample of commercial, Medicare Advantage and Medicaid plans.

Lead author James Heyward, MPH, a research data analyst at the Johns Hopkins Center for Drug Safety and Effectiveness, found a wide range of copayments for nonpharmacologic care for pain, such as chiropractic care and physical and occupational therapy. One commercial health plan, for example, required their members to pay a co-pay of as much as $60 per encounter for chiropractic care. Meanwhile, in the commentary, Christine M. Goertz, DC, Ph.D., and Steven Z. George, PT, Ph.D., cite research that shows health plans’ preferred generic opioid prescription costs members only $10 a month.

While follow-up chiropractic care visits typically only take 10 to 15 minutes, patients still need to leave home or work and cope with weather, traffic and parking—having to then pay a large copayment is a significant additional burden that can dissuade them from choosing the safer and more effective treatment plan. The financial incentive to refill a prescription must be weighed against the cost of adverse side effects, including misuse, abuse, addiction and in some cases fatality. Despite the convenience of simply taking a pill, choosing a much safer, more effective and less intrusive option should be encouraged and embraced, especially when the opposition could potentially cost one their life.

Overcoming barriers to care

To help stem the opioid crisis and steer more Americans toward evidence-based, effective, clinical pathways for pain management, health insurers and government healthcare policymakers cannot simply move opioids to a higher price tier or require a more rigorous preauthorization process for the medications. In fact, the Economic Policy Institute has found that increased cost-sharing in health plan policies tends to burden those patients who need the care the most, leading them to forgo care.

Health plan members and beneficiaries should instead be incentivized to pursue nonpharmacological care for their chronic, neuro-musculoskeletal pain. That means reducing copayments to at least the same levels as generic prescription opioids. In addition, the Heyward study found that more than half of all insurers placed visit limits on chiropractic care, physical and occupational therapy, while others instituted medical necessity reviews and other preauthorization requirements. Eliminating burdensome administrative requirements and visit limits would encourage patients to make these drug-free, effective therapies an unobtrusive part of their lives and integral to their long-term, chronic pain management strategy.

Multidisciplinary coordination and collaboration

What may help in this regard is improved coordination and collaboration by health insurers regarding the most effective, evidence-based care. In interviews with health plan leaders, Heyward found a “low level of integration between coverage decision making for nonpharmacologic and pharmacologic therapies, such as through the use of step therapy requirements that encourage use of physical therapy before initiation of long-acting or extended-release opioids.”

Collaboration and coordination, however, is essential to producing optimal outcomes. As recently highlighted in an article in Becker’s Spine Review, doctors of chiropractic are highly beneficial contributors to collaborative, comprehensive and patient-centered care teams. The article summarized four recent independent studies published in academic journals that demonstrated patient satisfaction, improved health outcomes and ease of integration with chiropractic care. For example, a four-year, randomized controlled trial involving 750 active-duty military personnel found that their low back pain intensity and disability improved by incorporating chiropractic care compared to clinical pathways without the care.

Toward evidence-based, patient-centered policies

While the causes of our opioid epidemic are numerous, there are opportunities for health plans to reverse the trend. For example, in light of the recently passed federal opioid legislation, the Centers for Medicare and Medicaid Services should seek input from doctors of chiropractic and other practitioners of evidence-based, nonpharmacological pain management care to design its new policies.

Given that a recent Gallup-Palmer College of Chiropractic report showed that 79% of Americans would prefer a drug-free treatment for pain before considering an opioid, it behooves public and commercial health plan leaders to remove the barriers to effective and preferred care pathways for chronic pain by making them more affordable and accessible for their members and beneficiaries.

About the author:

Sherry McAllister, DC, is executive vice president of the Foundation for Chiropractic Progress and Foundation for Chiropractic Education. A not-for-profit organization, Foundation for Chiropractic Education (501c3) and the Foundation for Chiropractic Progress (501c6) provide information and education regarding the value of chiropractic care and its role in drug-free pain management.

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GUEST POST: Massage Therapy as an Integrative Part of Pain Management

Posted By American Massage Therapy Association, Friday, October 26, 2018

As the U.S. struggles with an opioid crisis and its devastating effects on lives, society and the economy, it’s important to look carefully at the role that comprehensive integrative pain management (CIPM) therapies such as massage therapy can play in mitigating aspects of this epidemic. Using massage therapy as a first line approach and as an integrated complement to other pharmacological and nonpharmacological approaches can produce an overall reduction of medical costs and help to avoid dependence on opioids. The American Massage Therapy Association (AMTA) is leading the effort to draw attention to the role of massage therapy in CIPM.

There is significant evidence supporting the inclusion of massage therapy for many important patient health treatments, including those for chronic pain management (such as back pain, headache, carpal tunnel syndrome, osteoarthritis, neck and shoulder pain, fibromyalgia, and hospice care), behavioral health treatment (anxiety and stress, depression, PTSD, and substance use disorder recovery), rehabilitation/physical training (athletic train­ing/injury treatment, ergonomics and job-related injuries, cardiac rehab, joint replacement surgery, and scar management), and acute medical conditions (cancer management, post-operative pain, lymphatic drainage, and maternity and newborn care).

When massage therapy is part of a comprehensive integrative approach to a variety of health conditions, massage therapists become important members of care teams. Using a team approach to care delivery means that physicians can delegate more responsibility to other health professionals, each of whom can then practice “to the top of their license” to support more efficient processes and improve patient health outcomes.

Opioid medications used for pain management have become highly abused drugs, leading to one of the worst public health crises in recent history. While at first opioids may be perceived as an effective and inexpensive pain treatment, the continual rise in the number of patients who come to struggle with opioid addiction increases both the human and financial costs in the long run. The widespread nature of this crisis has compelled leaders in medical, research, public health and political arenas to actively provide guidance and seek out viable and economically feasible non-pharmacologic interventions, which include massage therapy.

Too often, patients are given opioids for their pain issues when there are potentially complementary and alternative types of treatment or strategies that augment medication and reduce potential addiction, such as massage therapy.

According to the Joint Commission and the American College of Physicians, nonpharmacologic approaches or techniques like massage therapy can replace opioids for many types of pain. John Dunham and Associates calculates that number to be as many as 5 million of the 27+ million opioid patients in the United States. This has  the potential to reduce the number of people with addiction disorder by nearly 111,137 per year. The projection suggests providing massage therapy as a tool for pain management instead of opioids can save the United States as much as $25.99 billion per year.

In this sense, the benefits of massage therapy (in addition to reducing the patient’s pain) are twofold: reducing the number of people who potentially struggle with opioid addiction and reducing the impact on the American economy by up to $25.99 billion annually. This economic model is at the heart of AMTA’s recently published document, “Massage Therapy in Integrative Care & Pain Management.”

Encouraging medical practi­tioners to prescribe massage in cases where it would be an effective pain management tool, and encouraging insurance compa­nies to cover it, can clearly help decrease the costs of opioid addiction. As stated in a recent letter from the National Association of Attorneys General to the America’s Health Insurers Plans (AHIP), massage therapy is not the only solution to this problem, but it is an important part of a comprehensive national approach to reducing addiction and its attendant costs.

Massage therapy is recognized by the National Institutes of Health (NIH), and included in nonpharma­cological pain guidelines issued by The Joint Commission, as well as the American College of Physicians (ACP) and the Federation of State Medical Boards. And, in its revision for 2019 coverage, the Medicare Managed Care Manual Chapter 4 - Benefits and Beneficiary Protections recommends the following:

“Medically-Approved Non-Opioid Pain Management (PBP B13d, e, or f ): Medically-approved non-opioid pain treatment alternatives, including therapeutic massage furnished by a state licensed massage therapist. “Massage” should not be singled out as a particular aspect of other coverage (e.g., chiropractic care or occupational therapy) and must be ordered by a physician or medical professional in order to be considered primarily health related and not primarily for the comfort or relaxation of the enrollee. The non-opioid pain management item or service must treat or ameliorate the impact of an injury or illness (e.g., pain, stiffness, loss of range of motion).”

A comprehensive approach to pain relief and management, which includes massage therapy, is an important step for health care in the United States.

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Pain Continues to Dominate the National Conversation: News from Congress, FDA, and HHS

Posted By Katie Duensing, Thursday, October 11, 2018

Congress has overwhelmingly passed the SUPPORT Act (HR 6), and the President is expected to sign the bill into law in a signing ceremony on October 24th. The massive 660-page bill is the second piece of sweeping legislation to pass in two years related to the opioid overdose and misuse epidemics, the first being the Comprehensive Addiction and Recovery Act of 2016 (CARA). While the legislation’s primary focus is on substance use disorder treatment and prevention, there is also some focus on comprehensive integrative pain management. In part:

  • Section 1010 directs the Centers for Medicare & Medicaid Services to issue guidance documents to States regarding mandatory and optional items and services that may be provided under a State plan for non-opioid treatment and management of pain, including, but not limited to, evidence-based, non-opioid pharmacological therapies and non-pharmacological therapies.
  • Section 6086 requires the Secretary of Health and Human Services to submit a report to Congress containing options for revising payment to providers and suppliers of services and coverage related to the use of multi-disciplinary, evidence-based, non-opioid treatments for acute and chronic pain management for individuals entitled to benefits under part A or enrolled under part B of title XVIII of the Social Security Act.

The Food and Drug Administration recently released an updated version of their Opioid Analgesic Risk Evaluation and Mitigation Strategy (Opioid REMS). Unlike previous iterations of the Opioid REMS, the new strategy stresses the need to utilize comprehensive integrative pain management as a part of a well-rounded treatment plan. In part, the strategy states that health care providers (HCPs) treating patients with pain should:  

  • Be knowledgeable about the range of therapeutic options for managing pain, including nonpharmacologic approaches and pharmacologic (non-opioid and opioid analgesics) therapies, upon completion of educational activities related to the Opioid REMS.
  • Attempt to overcome potential barriers when managing patients with pharmacologic and/or nonpharmacologic treatment options, such as lack of insurance coverage or inadequate availability of certain HCPs.
  • Be knowledgeable about the range of treatment options available, the types of pain that may be responsive to those options, and when they should be used as part of a multidisciplinary approach to pain management.

The second meeting of the Pain Management Best Practices Inter-Agency Task Force (Task Force) was held September 25th-26th in Washington, D.C.  The Task Force considered public comment, deliberated, and voted on the draft Task Force recommendations for acute and chronic pain management. The draft recommendations are expected to be released to the public near the end of October or the beginning of November, at which time a 90-day public comment period will commence.

The National Institutes of Health has released several Funding Opportunity Announcements specific to pain research as part of the HEAL (Helping to End Addiction Long-term) Initiative. Funding is available for research related to:

  • Analytical and/or Clinical Validation of a Candidate Biomarker for Pain
  • Discovery and Validation of Novel Targets for Safe and Effective Pain Treatment
  • Chronic Overlapping Pain Conditions

A complete list of funding opportunities and due dates can be found here.

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Update, 10/26/2018:

The SUPPORT Act was signed into law on October 24, 2018.

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Guest Post: Yoga Therapists as Interprofessional Communicators

Posted By Matthew J. Taylor, PT, PhD, C-IAYT, International Association of Yoga Therapists, Wednesday, August 22, 2018

When the Integrative Pain Care Policy Congress gathers in Boston this November, a “new kid” will be in attendance. I will be there to represent the yoga therapy profession on behalf of the International Association of Yoga Therapists (IAYT), a sponsor of the 2018 Policy Congress.

“A yoga what?” you might rightly ask. That’s right, yoga therapy is a profession. In this blog, I want to share some of the exciting processes IAYT has implemented related to interprofessional communication and interprofessional pain education, as well as offer a brief introduction to the profession of yoga therapy. It’s my hope that when we meet to congress (con = together; gress = walk) in November, I might learn how your organization is implementing similar processes.

What is Yoga Therapy?

Yoga therapy is both very old and quite new. In the past decade, the nascent profession of over 5,500 members from over 50 countries and with 3,600 credentialed therapists has:

Yoga therapists are distinct from yoga teachers by both breadth and depth of training (learn more). While this modern expression of yoga therapy is young, we are rooted in a long history of development. We can rightly lay claim to being the “early adapters” to the idea of integrative, which was referenced in the 6th century BCE in the Taittiriya-Upanishads.  The development of our profession hasn’t led to the ingrained siloes of disciplinary isolation that other professions have faced, as yoga inherently considers the multiple aspects of being human (physical, psycho-emotional, social, and spiritual). As such, I believe that yoga therapists can help lead in modeling the “sewing back together” (sutras) of interprofessional communication and education.

Interprofessional Sutras: Healthy Conversations as the Fabric that Unites

The past two years at IAYT’s international symposium (www.sytar.org) we have invested time, training, and action inquiry into becoming effective interprofessional communicators. Given our advantage of being rooted in an integral worldview, we asked, “How is it we can be catalysts for healthy conversations to facilitate suturing/sutra-ing collaborative care together for those in pain?” As with every integrative process, we realized we had to work on ourselves first!

The Inquiry Processes

In 2017, IAYT brought together multiple senior professionals to demonstrate/practice interprofessional dialog of learning “with, from, and about” as foundational to interprofessional pain education (IPE)1. The afternoon session with the rehabilitation community professionals representing many different disciplines involved a lively interaction based on a complex chronic pain case report, with audience interaction and collecting “next action” proposals from the experience.

This year, when our community of diverse professionals next convened, those actions proposals were then introduced in an all-day session during which the 80+ participants “saw one, did one, and taught one” in groups of mixed rehab professionals that included yoga therapists, physicians, mental health professionals, dieticians, physical and occupational therapists, and more. We moved between multiple learning experiences, collecting feedback and insights to identify specific opportunities and barriers to practice. The day concluded with participants committing to return home and initiate similar IPE experiences in their local networks, drawing from our collected insights and guidelines.

What Did We Learn?

Fascinatingly, from the many skills and qualities that IAYT has identified over the past two years of our process, the outcomes can all be categorized as requiring practices in embodied and enacted domains as described by Roshi Joan Halifax, PhD for priming for compassion2. Equally gratifying was that these practices include the domains that describe a full yoga practice. Here’s a very short sample:

  • Attention: Sustaining and returning attention to deeply listening vs. preparing a rebuttal or contrary position is key.
  • Affective: Being able to sense affect in one’s self and the other minimizes reactionary responses and illuminates deeply held biases/assumptions.
  • Insight: Occurs via presence and ability to not react from habit out of aversion or attachment.
  • Intention: Regularly returning to the larger shared intention grounds the other skills and maintains focus.
  • Embodiment: None of the above are possible without sustaining attention to our lived body experience moment to moment, and that is enhanced by regular practice.
  • Enaction: Nothing beats “doing it”. Most learning comes from regular and frequent engagement with others with the above qualities and intention to learn “with, from, and about” others.

All of these domains reinforce the primacy of how each participant in IPE and communications ought to sustain their personal integrative practice in order to “show up” primed for effective and optimal engagement.

What are the Implications for the Policy Congress?

As we 100 attendees of this November’s Integrative Pain Care Policy Congress enter our busy autumn season, maintaining our integrative self-care practices is a critical component for our interprofessional success. Priming ourselves to be with so many others having many different agendas and priorities will be good “preventative medicine” to insure we can “walk together” (congress!) in fulfilling our shared intention of Patanjali’s Yoga Sutra 2.16:

Heyam-Dukham-Anagatam

“The pain that is yet to come may be avoided.”

Each of us brings an important “thread” to sew together an integrative tapestry of integrative pain care policy that will require the best of each of us.

I look forward to meeting all of you in Boston!

 

1. Gordon, DB, Watt-Watson,J, Hogans, BB. (2018) Interprofessional pain education – with, from, and about competent, collaborative practice teams to transform pain care. Pain Reports: 3; e663.

2. Halifax, J. (2012) ‘A heuristic model of enactive compassion.’ Curr Opin Support Palliat Care 6 2: 228-235.

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Guest Post: Oregon Makes a Bad Proposal to “Fix” the Opioid Problem

Posted By Bob Twillman, Ph.D., FACLP, Executive Director, Academy of Integrative Pain Management, Tuesday, July 31, 2018

As I’ve said many times, to solve the complex problems of opioid misuse and overdose, policymakers across the country are blindly and blithely reaching for the simplest solutions. Typically, these solutions focus on reducing opioid prescribing to--or beyond--the bare minimum. Because these policies often are enacted with very little forethought and very little concern for the unintended consequences, policymakers sometimes unhappily discover after the fact that they may not have solved the original problem, but instead, have created a new one that may be even worse. This “ready, fire, aim” approach to policymaking, is, I fear, what we are facing now in Oregon, and we’re not going to sit idly by while it happens.

Currently, Oregon’s Health Evidence Review Commission (HERC), through its Value-based Benefits Subcommittee (VbBS), is considering a policy proposal from the state’s Chronic Pain Task Force that would deny coverage of opioids for most chronic pain conditions beyond 90 days, mandate the taper and discontinuation of opioid therapy for patients currently receiving it, and instead cover only a variety of non-opioid treatments for people living with long-term pain. While AIPM strongly supports increased use of nonpharmacological treatments and educates practitioners on the benefits of an integrative approach to treating pain, we are gravely concerned with the access to care issues that would be implicated if this policy were to be adopted as it is written.

This policy proposal will apply to all Oregon Medicaid patients diagnosed with conditions of the back and spine, and with chronic pain, except those who qualify for palliative care. Under the current proposal, between six weeks and 90 days, the use of opioids will only be allowed if several conditions are met, including that they must be prescribed in conjunction with therapies such as spinal manipulation, physical therapy, yoga, or acupuncture. What’s more, no opioids whatsoever will be covered after 90 days except for purposes of tapering a patient down to 0 MME/day within one year, regardless of how a patient’s pain and function respond to the taper.

Given that AIPM’s top priority is advancing access to integrative pain care, it would be easy to assume that we would support this policy change—we do not.

Health care providers treating patients living with complex pain conditions need access to all the tools in the toolbox, including both opioid and non-opioid medications, and non-pharmacological treatments. While we focus on removing barriers to non-pharmacological treatments that have not, to date, been adequately covered, we also have to be vigilant to prevent the erection of new barriers that block our access to tools that have been fully available. While some ratcheting back of opioid prescribing for chronic pain is not only appropriate but necessary, it should not be an all-or-none proposition. Despite the scarcity of randomized controlled trials of the long-term efficacy of opioids (which, by the way, is the same scarcity of RCTs we face with non-opioid treatments for pain), we know from clinical experience that there are some people with chronic pain who do well on long-term opioid therapy, and whose quality of life is likely to be markedly diminished if this policy goes into effect.

We have three major concerns with this proposed policy:

  1. Despite hinging access to opioid treatment on use of one of more non-opioid therapies, the Oregon proposal makes no plan for ensuring that the covered non-opioid therapies are geographically accessible to patients, or that there is a sufficient supply of providers for these therapies. See AIPM’s letter related to access to care concerns.
  2. The proposed changes do not mention what action should be taken if the patient begins to experience clinically significant increases in pain and decreases in function upon tapering the opioid dose. Appropriate medical care requires that a taper to be paused, stopped, and possibly reversed, based on documentation of detrimental changes to the patient’s functioning resulting from the taper. See AIPM’s letter related to forced opioid tapering.
  3. The Oregon proposal is unsupported by current treatment guidelines related to opioid prescribing, including those issued by the Centers for Disease Control and Prevention (CDC) in 2016, Canada in 2017, the U.S. Veteran’s Administration, and professional medical associations. See the sign-on letter that I joined on behalf of AIPM.

While it was recommended that all comments for the August 9th meeting of HERC/VbBS be in by July 30 to ensure sufficient time for them to be considered, comments will still be accepted up until August 7th. Comments must be no longer than 1000 words and can be submitted to herc.info@state.or.us.

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Update 8/10/2018

Dr. Twillman testified at the in-person meeting of HERC/VbBS on August 9, 2018. See his testimony related to forced opioid tapering and the need for any taper plan to contain a provision allowing that taper to be paused, stopped, and/or reversed if lower doses are associated with poorer function.

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Guest Post: Physical Therapists Offer a Comprehensive Strategy to Combat the Opioid Crisis

Posted By Kara Gainer, JD and Kate Gilliard, JD, American Physical Therapy Association, Friday, July 13, 2018

With the on-going public health crisis resulting from misuse and addiction to prescription opioids, more and more groups are seeking to identify and pursue solutions that address the crisis, including increasing patient and physician knowledge about different strategies to manage pain. The American Physical Therapy Association (APTA), a participant of the Academy of Integrative Pain Management’s Integrative Pain Care Policy Congress, continues to advocate for increased access to safe and effective nonpharmacological approaches to pain management.

To further these efforts, APTA’s website contains a comprehensive advocacy strategy for promoting safe pain management as well as a number of tools and resources for physical therapists and other health care professionals to use to advance person-centered care with multidisciplinary approaches that include physical therapy and other safe nonpharmacological treatment options. Highlights include a newly released white paper reviewing how opioid-centric solutions to dealing with pain have led to widespread misuse and addition. The paper highlights the valuable role of physical therapy in improving patient outcomes and altering the trajectory of the existing public health crisis. APTA’s position paper for federal advocacy provides a 3-point strategy to combat the crisis:

  1. Integrated Team Approach
    Public and private health plans should include benefit design, reimbursement models, and integrated team approaches that support early access to nonpharmacological interventions for the primary care treatment of pain.
  2. Early Access to Conservative Care
    Public and private health plans should reduce or eliminate copays and other policy barriers to care to increase access to person-centered nonpharmacological pain treatments and interventions.
  3. Education for Primary Care Providers and the General Public
    Primary care providers should have access to information on the value of nonpharmacological, person-centered interventions and how to appropriately assess, treat, and inform patients with pain.

In addition to its policy objectives, APTA’s #ChoosePT campaign educates the public about their options to manage pain. The campaign’s goal is to raise awareness about the benefits of treatment options that follow guidelines established by the Centers for Disease Control and Prevention (CDC). These options include alternatives like physical therapy.

APTA’s work complements the Integrative Pain Care Policy Congress in seeking solutions based on comprehensive integrative pain management and individualized care for people with pain. To learn more about APTA and its advocacy efforts to increase access to and awareness of nonpharmacological pain-management treatments, including physical therapy, visit the association’s website Advocating for Safe Approaches to Pain Management.

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Newly Passed Laws Increase Access to Integrative Pain Management

Posted By Katie Duensing, Wednesday, July 11, 2018

Similar to other chronic conditions like diabetes and high blood pressure, chronic pain isn’t typically cured, but is managed with a combination of therapies and approaches specific to the individual.  However, if you’re at all familiar with the current state of pain management in the United States, you already know that this kind of interdisciplinary integrative pain care is uncommon—in part because services other than traditional allopathic medical care are often poorly reimbursed and in part because these services are often in short supply in rural and other underserved areas. 

Recently, in an effort to optimally treat the 100 million Americans living with pain while reducing the prescription drug overdose epidemic, policymakers are beginning to truly understand the urgent need to ease access to alternative forms of treatment, including chiropractic care, physical therapy, massage therapy, and more.  During the 2017-2018 legislative sessions, we have witnessed an encouraging new trend: bills to advance comprehensive, integrative pain management are finally passing!

United States – In relevant part, the National Defense Authorization Act for Fiscal Year 2018 directs the Secretary of Defense to conduct a study on the effectiveness of the training provided to military health care providers regarding opioid prescribing practices. In doing so, the Secretary of Defense shall, in part, consider the feasibility and advisability of further strengthening opioid prescribing practices by means of developing methods to encourage health care providers of the Department to use physical therapy or alternative methods to treat acute or chronic pain.

LouisianaSenate Bill 285 (2018) prohibits a health insurance issuer from denying a non-opioid prescription in favor of an opioid prescription when prescribed for chronic pain. Effective August 1, 2018, it shall be unlawful for an insurer to deny a prescribed medication and attempt to substitute an alternative medication that requires any of the following:

  1. An increased number of pills per prescription.
  2. A higher Drug Enforcement Administration schedule medication than the one prescribed.
  3. The substitution of an extended release medication that does not have defined abuse deterrent properties for a prescription of a medication that does have defined abuse deterrent properties.

Maine – In March 2018, overriding the Governor’s veto, the legislature passed LD 1030 (2017), An Act to Require Health Insurance Coverage for Covered Services Provided by Naturopathic Doctors. A carrier offering a health plan in this Maine shall provide coverage for health care services performed by a licensed naturopathic doctor when those services are covered services under the health plan when performed by any other health care provider and when those services are within the lawful scope of practice of the naturopathic doctor. The law also institutes requirements related to deductible and co-pay limits and network participation. See AIPM’s letter of support (note: the bill was unfortunately amended after this letter was written—it had started as a non-discrimination bill that would have applied to all health care services, not just naturopathic doctors).

MissouriHouse Bill 1516 (2018) states that MO HealthNet shall, subject to appropriation, cover up to twenty visits per year for services limited to examinations, diagnoses, adjustments, and manipulations and treatments of malpositioned articulations and structures of the body provided by licensed chiropractic physicians practicing within their scope of practice. See AIPM’s letter of support for the companion bill, SB 597.

TennesseeSB 2155 (2018), which took effect July 1st, specifies that in developing or implementing any payment reform initiative involving the use of episodes of care with respect to medical assistance provided by the bureau of TennCare or the health care finance and administration (HCFA), the bureau and the HCFA shall exclude charges related to pain relief that decreases the use of opioids from the calculation of costs for any episode of care. 

WashingtonSenate Bill 5779 (2017) states that “Health transformation in Washington state requires a multifaceted approach to implement sustainable solutions for the integration of behavioral and physical health.” The legislation concerns behavioral health integration in primary care, requiring a complete review of payment codes available to health plans and providers related to primary care and behavioral health, including adjustments to payment rules if needed to facilitate bidirectional integration.

Finally, there are two important bills just shy of passage:

Delaware – The legislature sent Senate Bill 225 (2018) to the Governor on June 30, 2018. The bill awaits action from the Governor. This bill would prohibit numerical limits on physical therapy and chiropractic care and would ensure that practitioners understand when these treatments are indicated for particular patients by adding continuing education requirements for prescribers relating to risks of opioids and alternatives to opioids. The bill also creates a pilot program within the state employee health care plan that allows the use of massage therapy, acupuncture, and yoga for the treatment of back pain. See the letter of support from AIPM and US Pain Foundation.

VermontSenate Bill 224 (2018), as introduced and passed by the Senate, allows health insurers to subject health care services provided by a chiropractic physician to co-payments, but only so long as those co-payments are not greater than the amount of the co-payment applicable to care and services provided by a primary care provider under the plan.  However, the House dramatically amended the bill prior to passage, so the bill must go to Conference Committee before reaching the Governor. See the letter of support from AIPM for the as-introduced version of the bill.

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AHRQ, NIH, HHS, CMS & Congress: Looking to Integrative Pain Care to Reduce Opioid Use

Posted By Katie Duensing, Tuesday, June 19, 2018

Agency for Healthcare Research and Quality (AHRQ) released Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. The evidence-based Practice Center Program at AHRQ found that interventions that improved function and/or pain for certain conditions (such as low back pain, neck pain, knee and hip osteoarthritis, fibromyalgia, and tension headache) included spinal manipulation, acupuncture, cognitive behavioral therapy, massage, multidisciplinary rehabilitation, and more. While long-term evidence was sparse, there was no evidence suggesting serious harms from any of the interventions studied.

National Institutes of Health (NIH) leadership outlines the interdisciplinary research plan for the HEAL Initiative. Launched in April 2018, the HEAL Initiative is a trans-NIH effort to advance national priorities in addressing the opioid crisis through science with a focus on two primary areas: (1) improving treatments for opioid misuse and addiction, and (2) enhancing strategies for pain management. In part, critical components of the HEAL research plan include:

  • Supporting discovery and development of targets for non-addictive pain management, and therapies to treat those targets.
  • Collecting data to determine what factors lead acute pain to transition to chronic pain and how to block that transition.
  • Partnering with public and private groups to test effective treatments for pain and addiction using HEAL’s clinical trial networks.

The Pain Management Best Practices Inter-Agency Task Force held its first meeting from May 30-31 and received over 2,500 written comments. Created by Section 101 of the Comprehensive Addiction and Recovery Act of 2016 and administered by the Department of Health and Human Services, the Task Force is to identify (and propose solutions to) gaps or inconsistencies between best practices for pain management developed or adopted by Federal agencies. Following the initial meeting, three subcommittees were formed to further investigate:

  1. Medication; physical therapy; surgical and minimally invasive procedures;
  2. Psychological approaches; risk assessment; stigma;
  3. Complementary and alternative medicine; access to care; and, education.

Center for Medicare & Medicaid Services (CMS) released their Roadmap to Address the Opioid Epidemic. Related to the area of prevention, the roadmap encourages prescribers to manage pain using a safe and effective range of treatment options that rely less on prescription opioids. While the roadmap claims that significant progress has been made in identifying overprescribing patterns, it also acknowledges that CMS must build on these efforts by promoting effective, non-opioid pain treatments by identifying and developing solutions for treatment barriers that prevent people from accessing non-opioid pain treatments across Medicare, Medicaid, and private insurance plans.

Congress continues to consider scores of bills related to pain management, opioids, and substance use disorder.

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Guest Post: How Policymakers Can Redefine Pain Management

Posted By Institute for Patient Access, Monday, June 18, 2018

More than 42,000 Americans died from an opioid overdose in 2016. Meanwhile, millions of other Americans suffer from chronic pain. The situation poses a difficult question for policymakers: How do we meet the needs of pain patients without contributing to the national opioid crisis?

A newly released white paper from the Alliance for Balanced Pain Management offers some suggestions.  

In “Redefining Pain Management,” the group outlines five policy strategies for striking a balanced approach.

  1. Improve access to abuse-deterrent technology. “For many patients, opioids are still an effective and appropriate pain treatment,” the paper notes. Opting for abuse-deterrent formulations where appropriate can minimize the risk for household, family and community alike.  Abuse-deterrent formulations, which have been shown to reduce diversion by nearly 91 percent, are designed to resist crushing or dissolving for recreational use.
  2. Increase availability of balanced pain management. Balanced pain management can treat pain and decrease the need for opioids by offering more options for physicians and patients.  The approach includes treating chronic pain with integrated care, which might include physical or occupational therapy, chiropractic care, talk therapy and other approaches.  It also includes multimodal analgesia, an approach to acute pain that uses two or more techniques to reduce pain.
  3. Enable technology-based solutions. “Technology-based solutions also play a role in combating opioid abuse and overdose,” the white paper explains.  The paper notes that the Food and Drug Administration has approved more than 200 medical devices to help treat pain.  These include devices such as intraspinal infusion pumps, which reduce the amount of opioid needed by delivering the medication directly to the spinal cord, and neurostimulation, which disrupts pain signals to the brain.
  4. Encourage innovation on non-addictive pain treatments. Public policies can encourage a balanced approach to pain management.  The paper points to the Department of Health and Human Services’ Five-Point Opioid Strategy and the 2017 Integrative Pain Care Policy Congress as examples.
  5. Ensure stronger coverage policies. The paper notes that health plan design influences which pain management options patients and health care providers have at their disposal.  For integrative treatment and technology-based solutions to impact the opioid crisis, the paper explains, they must be accessible.

To learn more, read the Alliance for Balanced Pain Management’s “Redefining Pain Management.”

Note: This blog first appeared on the Institute for Patient Access Policy Blog.

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