Pain

In Vermont, as seen throughout the country, we are experiencing a crisis with the effects of opioids for pain management. People in acute or chronic pain are becoming addicted to these substances to get through each day. This dependency is paving the way for various degrees of struggle and suffering, and demands on our state’s human services. Why are we not more readily using the evidence-based alternatives to opioids?

The Joint Commission is an independent, not-for-profit organization that “accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.” So, the Joint Commission sets the standards of care in health care organizations.  On January 1, 2015, the standards of care for pain management were revised.

A part of the listed requirements for what should be addressed in a hospital’s policies for pain management is:

“The identification and management of pain is an important component of [patient]-centered care. [Patients] can expect that their health care providers will involve them in their assessment and management of pain. Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. The following examples are not exhaustive, but strategies may include the following:

Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.

Pharmacologic strategies: nonopioid, opioid, and adjuvant analgesics.

The hospital or clinic either treats the patient’s pain or refers the patient for treatment. Note: Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient’s current presentation, the health care providers’ clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.”

I realize this is a lot of clinical sounding language, but I’m sharing it here directly from the organization that standardizes much of medical care. I think it’s important to point out to the average one of us dealing with pain that the Joint Commission is requiring health care organizations to offer this variety of strategies. From my observation, though nonpharmacologic approaches are required according to these standards since they were revised over two years ago, they are still relatively rarely being utilized before the choice of opioid medication. The main reason I see for this is the lack of insurance reimbursement and the high cost of accessing these services, such as acupuncture and massage therapy. It’s logical that the insurance companies would save money on the cost of medication, surgery, and disability if some of these alternatives were the first course of action. I envision health insurance paying for twelve weeks of acupuncture, chiropractic, massage therapy, and/or relaxation therapy for the patient in pain before beginning a course of opioid medication. This is the case in other countries.

Vermont’s Medicaid is currently conducting a pilot program to study the effects of acupuncture for patients in chronic pain. If you are enrolled in Medicaid and are in chronic pain, you may very well be eligible for this program, offering twelve treatments over a two-month period. They are accepting patients until the end of March. Please feel free to contact myself to guide you if interested.

Managing chronic pain is one of the greatest challenges of most health care providers. Having accessible options, both pharmacologic and nonpharmacologic, that have quality evidence only makes good sense.