David, a 38-year-old father of four and five-year survivor of fungal meningitis, experiences the long-term effects of contaminated epidural injections that have left him with headaches, visual disturbances, tinnitus, adhesive arachnoiditis and fibromyalgia.
His story exemplifies the gap between state and federal health care laws and treatment protocols for those with chronic pain requiring high-dose opioid therapy, wrote Terri Lewis, PhD, in “States of Pain: Part II. The Influence of Regulations” in National Pain Report.
“High-dose opiates—depending on the document, set of guidelines and law you’re looking at—are now being unilaterally redefined as addiction,” said the rehabilitation and mental health educator and clinician from Nashville, Tenn. “Our interactions with the care system are built on a scaffold of law, regulation, policy, professional practices, insurance regulations, guidelines and personal resources. This scaffold is destabilizing across the system as new guidelines and reactive public responses to increasing opioid-associated overdoses seize the public imagination.”
Dr. Lewis cited a conflict between the Controlled Substances Act, which classifies opioids as a Schedule II narcotic, and the Drug Enforcement Administration (DEA).
“The driver is rooted in DEA policy in managing Schedule II narcotics and comingling this activity with interdiction of illegal distribution to the streets,” she explained. “The DEA will claim they do not tell individuals how to practice. But they do influence choices about what is being done to treat at the local level by the thrust of current prosecutions.”
“It’s not so much classification of opioids as Schedule II substances as [it is] state laws and guidelines governing who can prescribe them, when and how that may pose a barrier to managing chronic pain,” said Joe Rotella, MD, chief medical officer, American Academy of Hospice and Palliative Medicine. “Because of a shortage of palliative medicine and pain specialists, many people with chronic pain receive care solely from a primary care provider.”
Larry Driver, MD, who sits on the professional education committee and chairs the CME oversight committee for the American Academy of Pain Medicine, agreed, stating, “We certainly need more physicians and other health care professionals who can provide appropriate and safe pain management and palliative care. This includes being aware of patients at risk for medication misuse or abuse and potential addiction, and taking steps to mitigate those risks while caring for the patient.”
Indeed, said Dr. Lewis, “we need more physicians trained in family medicine, physiatry, neurology, pain management and allied health practitioners. We need designated, mandatory medical home programs located within physician practices in every state, and every insurer to reimburse for palliative, medical home and integrated treatment. Guidance, issued by the Federation of State Medical Boards, needs to be rewritten; and every state pain regulation ought to contain consistent, unifying language to distinguish acute from palliative and hospice pain care.”
She added that conflating addiction prevention within palliative and hospice care must be modified, so physicians can “treat the whole person.”
“It’s critical to elevate knowledge of appropriate prescribing of controlled substances across various providers and specialties,” Dr. Rotella said. “Today, there is little to no curricula on managing pain in medical and nursing schools.”
He pointed out that the Palliative Care and Hospice Education and Training Act, a bipartisan bill, “would expose medical students, nursing students, pharmacy students and social work students to palliative care education and training early on to develop skills in assessing and managing pain and evidence-based prescribing. Palliative care focuses on care coordination. So, expanding these skills can play a role in stemming opioid misuse.”