April 05, 2019 12:57 pm News Staff – An interagency task force working to solidify best practices for pain management should closely consult family physicians and refer to policy developed by the AAFP, which has focused considerable work on the issue, the Academy told HHS in a recent letter.
"The AAFP is committed to addressing the dual public health crises of undertreated pain and opioid misuse/abuse at both the national and grassroots levels," the AAFP said in an April 1 letter(3 page PDF) to Vanila Singh, M.D., chief medical officer for HHS' Office of the Assistant Secretary for Health. "To this end, the AAFP has formed a cross-commission advisory committee to address the multiple and varied issues involved."
The letter, which was signed by Board Chair Michael Munger, M.D., was sent in response to an HHS request for comments that was published Dec. 31 in the Federal Register regarding the Pain Management Best Practices Interagency Task Force's draft report on updates, gaps, inconsistencies and recommendations on pain management best practices.
The letter strongly encouraged HHS and the task force to consult the Academy's position paper on chronic pain management and opioid misuse and advised including family physicians in the task force's work on the final report.
"Both pain management and dependence therapy require patient-centered, compassionate care as the foundation of treatment," the Academy said. "Family physicians include these foundational elements in their relationships with patients. While our currently fragmented health care system is not well prepared to address these interrelated issues, the specialty of family medicine is suited for this task."
The letter also offered detailed feedback on specific points in the draft report, including the following:
The Academy called for renewed attention to the social determinants of health and numerous economic factors that complicate pain management.
"The AAFP is most concerned that the (draft report's) section on health disparities in racial and ethnic populations needs renewed attention," the letter said. "The recommendations do not address the grave issues identified in the gaps, and we encourage expedited data collection in this area."
Responding to the draft report's suggestion for early consultation with a pain management specialist, the letter said the final report should note that such specialists are not readily available in many parts of the United States, and it pointed out that such early consultation actually may be unwarranted.
"This recommendation could create further access issues and delays in patients getting needed care from pain management specialists, as a large number of patients fit the criteria for complex pain," the letter warned. "The AAFP is not aware of evidence that early referral to pain management specialists prevents complications, reduces loss of function or improves quality of life."
The Academy expressed concern that the draft report separates antidepressants and anti-anxiety medications.
"Doing so discounts that selective serotonin reuptake inhibitors remain the firstline treatment for anxiety for patients," the letter said. "The AAFP encourages the final report to explicitly present the level of evidence for different medications and to effectively distinguish medications within each class."
The Academy identified a potential issue in the draft report's section on restorative therapies -- specifically, one recommendation that calls for improving access to "harm-free, self-administered therapies" by making them available over the counter. Making such agents available without prescription, the AAFP said, "can easily lead to higher patient costs, since insurers may not cover OTC services and items."
Regarding a reference to vertebroplasty in the draft report, the AAFP noted that this procedure "is ineffective for treatment of vertebral compression fractures and should not be recommended."
Additionally, the Academy questioned a call within the draft report for "establishing criteria-based guidelines for properly credentialing physicians who are appropriately trained using interventional techniques to help diagnose, treat and manage patients with chronic pain for interventional procedures."
"The AAFP questions whether the draft report suggests all physicians be credentialed to perform joint injections and trigger point injections and would encourage the final report to not finalize this recommendation," the letter said. "Requiring specialty referrals will harm patient access, as these specialty providers may not be readily available across the country and could add an unnecessary cost and expense to patients and payers alike."
The draft report discusses "a large-scale, systematic, coordinated public campaign to address pain awareness" -- a tactic that could backfire, the Academy cautioned.
"Awareness campaigns are often used by commercial interests to sell products and, as such, the AAFP urges extreme caution about launching such a campaign without being clear that its goals are to reduce the stigma of chronic pain."
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