Policymakers Continue Focus on Non-Opioids for Pain Management 2023

In early 2020, PPM covered the rapid rise of non-opioid pain policies across the nation, as legislatures and insurers had begun focusing intensely on policies that encouraged, incentivized, and even mandated the use of alternatives to opioid therapy for the treatment of pain. Three years on, policymakers at all levels have continued their pursuit of shifting pain treatment from opioid therapy to non-opioids, resulting in a multitude of novel laws, research efforts, and guidance documents related to pain management options.

As reported in 2020, the federal SUPPORT Act, passed by Congress in late 2018, directed the Centers for Medicare & Medicaid Services (CMS) to issue guidance to all states regarding mandatory and optional items and services that may be provided under their plans for non-opioid treatment and management of pain, including, but not limited to, evidence-based, non-opioid pharmacological therapies and non-pharmacological therapies.¹ The guidance that was sent to states initially manifested as an informational bulletin in 2019² which, in addition to listing a wide variety of non-opioid pharmacologic and non-pharmacologic options for pain management, suggested to states that they may wish to consider pharmacy benefit management strategies such as prioritizing non-opioid analgesics in their coverage policies.

However, the federal government did not end efforts to transform the state of pain management with that CMS bulletin; rather, it has committed to an ongoing effort to improve access to, and understanding of, non-opioid approaches to pain, with ongoing research efforts and guidance aimed at educating clinicians, patients, and policymakers as to the variety of pain management approaches, the evidence for those approaches, and how to best make them accessible to patients.

After the publication of its 2019 bulletin, CMS continued its efforts to reduce pain and opioid use in the US through improved access to non-opioid therapies using a variety of tools and publications.

In 2021, CMS released its CMS Action Plan to Enhance Prevention and Treatment for Opioid Use Disorder.³ A key part of preventing opioid use disorder (OUD) is appropriately treating pain through use of evidence-based non-opioid therapies, so much of the “prevention” portion of the action plan focuses on enhancing patient care coordination and multidisciplinary pain care, identifying and supporting the use of effective non-opioid treatment options for pain, supporting state Medicaid agencies by identifying and sharing best practices in pain management, and investigating innovative payment models for multidisciplinary and multimodal pain care.

According to the CMS Action Plan, the agency is exploring a number of options, including reviews of both the evidence base and of current policies in order to identify how to best expand coverage for the full continuum of care for pain management.

CMS is further helping providers and patients to better understand the pain management options available to them via Medicare’s website, which has a section dedicated to pain management that explains which treatments are covered under Medicare Part B (medical insurance) and Medicare Part D (drug coverage).⁵ While Medicare Part B helps to pay for a variety of services, including acupuncture for chronic low back pain, behavioral health integration services, chiropractic services, occupational therapy, and physical therapy, Medicare Part D—which does still cover opioid therapy for appropriate patients—covers medication therapy management programs for patients with complex health needs.

Other Federal Agencies Lead Research Efforts to Expand the Evidence Base

In addition to the important work being done by CMS, other federal agencies have also been extremely active in recent years in their efforts to expand access to non-opioid therapies for pain management.

The National Institutes of Health (NIH) have been strongly supporting improved pain management through their Helping to End Addiction Long-term Initiative, known as the NIH HEAL Initiative. The HEAL Initiative is a trans-agency effort intended to speed scientific solutions to stem the national opioid public health crisis through the funding of hundreds of research projects nationwide. The results from these research projects will then help federal, state, and health system policymakers to implement new evidence-based policies. Funding from this initiative has supported many important research efforts related to advancing health equity in pain management, including: Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR); the Pain Management Effectiveness Research Network; and, Pragmatic and Implementation Studies for the Management of Pain to Reduce Opioid Prescribing (PRISM).⁷

The PMC supports a shared resource center and 11 large-scale pragmatic clinical trials, currently enrolling more than 8,200 study participants across 42 veteran and military health systems. Central to the PMC partnership is Whole Person Health – a central focus of NCCIH’s current Strategic Plan– which recognizes that health exists across multiple interconnected body systems and domains: biological, behavioral, social, and environmental. While PMC’s research specifically targets the military community, their growing body of evidence will ultimately benefit the general public as well.

These systematic reviews have already been relied upon by the CDC when the agency released its updated opioid prescribing guideline last year (see our ongoing analyses on implementation).⁹ It is highly likely that these reviews will continue to be relied upon by state and federal policymakers, as well as by private insurers, as future policies are developed relating directly to non-opioid care.

In addition to the numerous federal efforts aimed at encouraging a shift from opioid pain care to whole person care that embraces non-opioids at the core of treatment, state policymakers have also been active in this arena. New York and Minnesota provide two very different examples of how states are taking action.

In New York, effective December 23, 2022, medical practitioners are now required to consider, discuss, and refer or prescribe non-opioid treatments before starting opioid treatment for neuromusculoskeletal conditions that cause pain.¹⁰ The new law specifically states that non-opioid treatment alternatives include, but are not limited to, acupuncture, chiropractic, massage therapy, physical therapy, occupational therapy, cognitive behavioral therapy, non-opioid medications, interventional treatments, and non-clinical activities such as exercise. While the new law mandates use of non-opioid therapy prior to initiating a patient on opioid therapy, it does not mandate insurance coverage for these therapies, leaving patients to potentially face additional out-of-pocket expenses. The mandate does not apply to patients being treated for cancer, post-surgical care, or to hospice or other end-of-life care.

Key findings from the projects were that expanding insurance coverage for non-pharmacologic modalities coupled with increased provider education reduces healthcare spending and that utilization of alternatives such as yoga and acupuncture result in a reduction of medication use and an increasing desire in patients to cease opioid use.¹¹ Based on these findings, it was recommended by the state’s Department of Health that non-narcotic pain management be promoted as the standard of care; insurance coverage for non-pharmacologic treatments be expanded; provider knowledge of alternative therapies be increased; and community health workers be embedded into primary care clinics.

While governmental policymakers seem to be in agreement that the expanded use of non-opioid therapies is the future of pain care, a number of barriers to this sort of care will need to be addressed in order to see substantial change. Delivering effective non-opioid care will require policy changes that promote awareness, acceptance, availability, accessibility, and affordability.¹² In addition, policies will need to be flexible enough to allow providers to deliver the most optimal treatments to patients based upon their individual circumstances, with reimbursement structures providing clinicians with adequate time for a complete pain assessment and follow-up care. Finally, policies will need to take into account the availability, or lack thereof, of a diverse pain management workforce within the specific communities in which patients reside.¹³

There are no simple solutions to the complexities facing the pain management world. However, with the support of continued research efforts, thoughtful policymakers, and engaged clinicians, there is a world of opportunity right now to help to shape the future of pain care.