President's Message

National Academies of Sciences, Engineering, and Medicine (NASEM)

Last month, the AAPM released a public comment applauding the National Academies of Sciences, Engineering, and Medicine (NASEM) for its efforts in preparing the July 13, 2017 report, Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use: “The report, which appropriately details the pressing public health challenges pertaining to the burden of pain on Americans and the increasing toll of the opioid epidemic on society, provides a number of thoughtful recommendations to increase understanding of the interplay between the two.”

The decision by AAPM to support publicly the recommendations of the report was not particularly difficult to make. The authors appropriately address the dual public health burdens of undertreated pain and opioid use disorder. Additionally, they include a call for investment in research to better understand pain and opioid use disorder, the development of comprehensive pain education materials and curricula for health care providers, and facilitation of reimbursement for comprehensive pain management programs. What’s not to approve about this.

But like many of you, I practice pain medicine “in the trenches.” And after reviewing parts of the report, I found myself wondering about its implications for all of us “pain docs” and our patients. Here’s some background and perspective to put the report in context.

What Is NASEM and How Did the Document Come about?

The FDA and the National Academies of Sciences, Engineering, and Medicine (the National Academies) convened an ad hoc committee in order to update the state of pain care since the 2011 Institute of Medicine (IOM) report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The ad hoc committee’s task was to better characterize the epidemiology of the opioid epidemic and efforts aimed at curtailing it, identify strategies the FDA and others can take to respond with special considerations for individuals and society, and develop research questions that can better assist FDA in implementation.

Why Does the NASEM Report Matter to Pain Physicians?

The report clearly acknowledges that “pain is a complex syndrome” that is challenging to measure and treat and includes significant psychosocial factors, vocational impacts, and patient-specific suffering that requires access to a broad range of treatments. For some of us, this may be the validation we have hoped to see. The question is whether this acknowledgement will translate into the practices of healthcare institutions as well as payers and formularies.

The report highlights the point that the “vast majority of patients who are prescribed opioids don’t misuse them.” The report also correctly focused on less frequently known factors related to opioids beyond the more commonly recognized analgesic impact, such as other positive reinforcing factors, including producing feelings of pleasure and a relaxed state, and in some patients with prolonged use, the overreliance on the drug, Overreliance on the drug effects could be characterized as misuse or more definitively opioid use disorder (OUD). This subtlety recognized by the authors underscores the complexities most pain clinicians appreciate day in and day out when managing opioids as part of a treatment plan and as part of the complex and unique set of factors our individual patient presents with.

The final text is an exhaustive 400 page document, summarized in 15 pages, highlighting 21 recommendations that span various topics including trends in opioid use and harms; approval and monitoring by the FDA; strategies for addressing the opioid epidemic, including those for reducing demand and harm; and addressing issues not only involving prescribers, but payers and other stakeholders.

This in-depth look at the opioid epidemic and its intersection with the management of pain helps to paint a more complex picture of the current environment of pain medicine beyond the simplistic notion that the opioid epidemic was fueled by over-prescribing of opioids by poorly trained or misguided practitioners. Rather, the report clearly emphasizes that the “ongoing opioid crisis lies at the intersection of two substantial public health challenges—reducing the burden of suffering for pain and containing the rising toll of the harms that can result from the over use, misuse, and abuse of opioid medications.” Again, for you and me, this is an important milestone, which presents the practice of pain medicine—not as a contributor to the opioid epidemic but rather as an important leader in helping to ameliorate the epidemic of opioid overdose deaths and morbidity on one hand while providing comprehensive, safe, and biopsychosocially informed pain care for our patients that deserve the highest quality of care and compassion.

Notably, the authors explain that a sustained and coordinated effort will be needed to impact the current epidemic, which will take significant time, cooperation from all stakeholders, public health interventions, and “scientifically grounded policies and clinical practices to promote responsible prescribing” and through research aimed at developing alternatives to opioids for the treatment of pain in addition to supporting greater use of multidisciplinary care, behavioral health interventions, and other evidence-based treatment interventions. This more comprehensive approach is at the core of how we practice pain medicine.

Take a few moments to download the entire document, which requires a payment to NASEM, or review the links here, which include report highlights and recommendations. The recommendations, which I’ve reproduced below, help summarize the breadth of the report including considerations around future research, clinical care, education and regulatory guidance.

Recommendations

Steven P. Stanos, DO
President, American Academy of Pain Medicine

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