Dear President Obama:

On Friday, March 18, 2016, HHS Secretary Sylvia Burwell released the long-awaited National Pain Strategy: A Comprehensive Population-Health Strategy for Pain (NPS). The National Pain Strategy report is an epiphenomenon of the Institute of Medicine’s June 2011 report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, which concluded that a cultural transformation is called for “in the way pain is perceived, judged and treated.” We commend the Department of Health and Human Services for beginning the NPS report where the IOM committee left off by stating in the report’s Executive Summary:

Key to a cultural transformation in pain care is a greater understanding – among members of the public and people with pain alike – of important aspects of chronic pain and its appropriate treatment. The National Pain Strategy recommends a national public awareness campaign involving public and private partners to address misperceptions and stigma about chronic pain. The learning objectives of the campaign would emphasize the impact and seriousness of chronic pain and its status as a disease that requires appropriate treatment.

It goes further to say:

“In addition, an educational campaign on the safer use of pain medications that is targeted to people with pain whose care includes these medications is recommended.”

PAINS, a national alliance of individuals who lead professional societies, patient advocacy organizations, bioethics centers, and policy groups, some of whom served on the IOM Committee, was organized to advance the vision and recommendations set forth in Relieving Pain in America. PAINS is now pleased to support those actions specifically called out in the press release announcing the NPS Report, i.e.,

  • Developing methods and metrics to monitor and improve the prevention and management of pain.
  • Supporting the development of a system of patient-centered integrated pain management practices based on a biopsychosocial model of care that enables providers and patients to access the full spectrum of pain treatment options.
  • Taking steps to reduce barriers to pain care and improve the quality of pain care for vulnerable, stigmatized and underserved populations.
  • Increasing public awareness of pain, increasing patient knowledge of treatment options and risks, and helping to develop a better informed health care workforce with regard to pain management.

The press release also noted that the strategy “is an essential element” of federal efforts at HHS to address the “opioid epidemic associated with more than 28,000 opioid-involved overdose deaths” in 2014, according to the latest data from the Centers for Disease Control. Although improving pain care and reducing the burden of chronic pain for the 100 million Americans who live with it and those who care for them is the primary focus of PAINS, we too are concerned about both public health issues and believe that the lack of balance between efforts to reduce the burden of chronic pain and efforts to reduce the abuse of opioids and deaths associated with them pits one vulnerable population against another. It is our belief that best chance of achieving either of these goals requires that they be addressed in tandem.

We acknowledge that there is sparse clinical trials evidence for the efficacy and safety of opioids beyond 12 weeks and also that opioids are often abused and can be lethal if prescribed in unsafe ways and/or co-administered with other medications. At the same time, however, opioids are listed on the World Health Organization’s Model List of Essential Medications, indicating that they are vital to meet the minimum health requirements for safe and cost-effective management of pain, which is listed as a priority health condition in all countries. To address the dual realities of the essential need for opioids for pain and the unacceptable level of morbidity and mortality associated with misuse and abuse of these substances, we must draw on public health principles that utilize a harm reduction approach. Public health strategies that address greater highway safety and minimize motor vehicle accidents and mortality come to mind as conceptual models for health policy approaches concerning opioids. This implies that any current and future health policy, regulation and/or clinical practice guidelines should:

  • be based on the best available scientific evidence,
  • educate all those involved, i.e., providers, patients and their families, and the general public about potential risks and benefits of opioids and other pain medications,
  • assure that patients who require opioids for chronic pain have access to them,
  • provide mechanisms to manage the risks, e.g., naloxone, and
  • promote common sense regulations to minimize the harm from misuse, abuse and unsafe prescribing.

One critical gap in our knowledge base is the degree of overlap between the population of patients with the disease of chronic pain who are prescribed opioids for legitimate medical purposes and the population of individuals with the disease of addiction, particularly those whose first exposure to opioids such as morphine and oxycodone occurs in the context of management of their pain. Those responsible for implementation of the National Pain Strategy must vigorously advocate for more research in the basic neurobiology of pain mechanisms, but also clinical and social science research to better understand the risks of iatrogenic addiction.

The IOM pain report emphasizes the need for comprehensive pain management based on a conceptual model of pain as a biopsychosocial phenomenon, requiring not just pharmacological management with drugs such as opioids and other adjuvant analgesic medications, but as importantly involving integrated and coordinated behavioral and physical modalities of treatment. The committee rejected conflating the use (and potential misuse) of opioids with quality pain care. Ironically, comprehensive, multi-modal pain management clinics that demonstrated evidence of effectiveness in improving the function and quality of life of people with chronic pain have all but disappeared because our past models of financing medical care made them unsustainable. Recognizing the emerging realities of chronic pain as a disease requiring medical, emotional, physical and life-style changes, those responsible for implementing the new National Pain Strategy must advocate strongly for sustainable funding models of multi-disciplinary, multi-modal pain management approaches that provide this comprehensive care. It is also likely that the re-creation and proliferation of comprehensive pain management clinics will decrease the utilization of prescription opioids for chronic pain.

PAINS calls on you to do three things:

  1. Immediately direct the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services to develop and, before the end of 2016, initiate a plan across all federal agencies to restore balance between federal efforts to reduce drug abuse and efforts to reduce the burden of pain in order to establish parity between these two critical public health issues. To do so will require developing a new narrative about chronic pain and opioid abuse.
  2. Designate a specific agency to be responsible for implementation of the National Pain Strategy Report and establish an independent work group, including people living with both chronic pain and opioid abuse disorder and/or family members, primary care providers and specialists who treat chronic pain, behavioral health experts, complementary care providers, third party payers, patient advocacy groups, and bioethicists to:
    • Establish a consolidated timeline for implementation of the NPS Report’s objectives and strategies,
    • Monitor the agency’s progress,
    • Measure the impact of those living with chronic pain, giving special attention to historically under-served populations, and
    • Issue a public annual progress report.
  3. Direct CMS to establish chronic pain care as an essential health benefit as quickly as possible and to adequately fund:
    • Comprehensive chronic pain care provided in primary care medical homes and inter-disciplinary, comprehensive pain clinics,
    • Evidence-based complementary therapies, including yoga, massage therapy, acupuncture, chiropractic and osteopathic manipulation (those therapies specifically listed in the DOD pain report), and
    • Abuse deterrent opioid formulations.

There is no one in this country who does not know the destruction that unrelenting pain and/or substance abuse can cause to an individual and that person’s family. We have also seen the wholesale destruction done by opioid abuse and addiction. The opioid epidemic has caught the attention of the media, politicians, policy makers and the public. Unfortunately, the same is not true about chronic pain, which has been referred to as a “silent epidemic.” Without question, there is a relationship between these two public health issues, and it is our view that, also without question, they must be addressed in tandem and with parity. We call upon you and your administration to fully implement the National Pain Strategy Report and to use it as a springboard to improve the lives of all Americans who struggle to live with chronic pain or substance abuse disorders. PAINS stands ready to be of assistance in any way possible.

With respect,

American Pain Society Chicago, IL

Theresa Boehm Volunteer Coordinator Franciscan Mission Warehouse Citizen Advocate for PAINS Independence, MO

James W. Broatch, MSW Executive Vice President and Director Reflex Sympathetic Dystrophy Syndrome Association Milford, CT

Patricia Bruckenthal, PhD, APRN-BC, FAAN Chair and Associate Professor Department of Graduate Studies in Advanced Practice Nursing Past President, American Society for Pain Management Nursing Stony Brook, NY

Maggie Buckley Chair, The Pain Community Volunteer Patient Advocate Alamo, CA

Margaret Faut Callahan, CRNA, PhD, FNAP, FAAN Provost, Health Science Division Professor, Niehoff School of Nursing Loyola University Chicago Maywood, IL

Center for Practical Bioethics Kansas City, MO

Jan Chambers Founder and President National Fibromyalgia & Chronic Pain Association

Barbara Chlumsky Chronic Pain Patient Spouse of one who suffered for 28 years Olathe, KS

Myra J. Christopher Kathleen M. Foley Chair in Pain and Palliative Care Center for Practical Bioethics Kansas City, MO

Lee Bryan Claassen, CAE Executive Director Interstitial Cystitis Association McLean, VA

James Cleary, MD, FAChPM Associate Professor of Wisconsin University of Wisconsin Director, Pain and Policy Studies Group Madison, WI

Alana Cole Newton, MA

Michael D Collins Overland Park, Kansas

Dr. Vern Commet, DNP NOVA Health Neurosurgery Services Best Practices Medical Clinic Yakima, Washington

Ann J. Corley, MS Special Projects Coordinator PAINS Project Lee’s Summit, MO

Jorge E. Corzo, MD American Academy of Pain Management San Juan, Puerto Rico

Cathy Crumrine Social Worker Emory Johns Creek Hospital Atlanta, GA

June L. Dahl Professor of Neuroscience University of Wisconsin School of Medicine & Public Health Madison, WI Andrea Denault Sterling, VA

Paul Denault North Fort Myers, FL

Larry C. Driver, MD President, Texas Pain Society Houston, TX

Gloria Duke, PhD, RN Tyler, TX

Linda Edmondson, LCSW Oklahoma City, OK

Jennifer A. Elliott, M.D. Associate Professor of Anesthesiology University of Missouri-Kansas City School of Medicine Kansas City, MO

Rhonda Leigh Enzinna PAINS Project, Citizen Leader Kansas City, MO

John T. Farrar, MD, MSCE, PhD Associate Professor of Epidemiology, Neurology, and Anesthesia Co-Director, Master of Science in Clinical Epidemiology Senior Scholar, Center for Clinical Epidemiology and Biostatistics University of Pennsylvania Philadelphia, PA

Steven D. Feinberg, M.D. Adjunct Clinical Professor Stanford University School of Medicine Palo Alto, CA

Mugur Geana, MD, PhD Shawnee, KS

Dr. Melissa Geraghty, PsyD Rago & Associates Naperville, IL

Joan McIver Gibson, PhD, Ethicist Founder/Director: Health Sciences Ethics Program (Retired) University of New Mexico Albuquerque, NM

Elizabeth B. Gilbertson Boston, MA

Harry J. Gould, III Professor of Neurology and Neuroscience Louisiana State University Health Sciences Center New Orleans, LA

Rev. Eric J. Hall, MDiv, MA President and Chief Executive Officer HealthCare Chaplaincy Network, Inc. New York, NY

Richard S. Hamburg Interim President and CEO Trust for America’s Health Washington, DC

Todd E. Handel, M.D. Interventional Physiatrist Clinical Assistant Professor, Brown Alpert Medical School Handel Center for Spine, Sports and Pain Intervention Providence, RI

Chris Hansen, President American Cancer Society Cancer Action Network Washington, DC

HealthCare Chaplaincy Network, Inc. New York, NY

Keela A. Herr, PhD, RN, AGSF, FAAN Professor and Co-Director, Csomay Center for Gerontological Excellence Associate Dean for Faculty College of Nursing The University of Iowa Iowa City, IA

Michael D. Hockley, Attorney at Law Spencer Fane LLP Kansas City, MO

Interstitial Cystitis Association McLean, VA

Lila Johnson Minneapolis, MN

Cynthia J. Johnston, Pharm.D. Assistant Professor, Pharmacy Practice Campbell University College of Pharmacy & Health Sciences Buies Creek, NC

Mary Janevic, MPH, PhD Assistant Research Scientist Center for Managing Chronic Disease Department of Health Behavior and Health Education University of Michigan School of Public Health Ann Arbor, MI

Karen Snow Kaiser, PhD, RN President of the Maryland Chapter of the American Society of Pain Management Nursing Columbia, MD

Karen Kiefer, RN-BC, BAIS o/b/o Garden State Chapter of ASPMN Legislative Chair Summit, NJ

N.L. Kopitnik, D.O North Florida Treatment Centers Spring Hill, FL

Robert Kronenberg, PharmD Director of Pharmacy HealthSouth Valley of the Sun Rehabilitation Hospital Glendale, AZ

Maria Kunstadter, DDS Dental Director of PAINS The Smile Salon, CEO Kansas City, MO

Julia Lee Ambassador, US Pain Foundation Topping, VA

Terri A. Lewis, PhD Assistant Professor Rehabilitation Patient Navigator Fungal Meningitis Outbreak National Changhua University of Taiwan

Cindy Leyland, EMBA Director of Program Operations and PAINS Project Director Kansas City, MO

Renee’ Mace Medical Lake, WA

Salimah H. Meghani, PhD, MBE, RN, FAAN Associate Professor, Department of Biobehavioral Health Sciences Associate Director, New Courtland Center for Transitions and Health University of Pennsylvania School of Nursing Philadelphia, PA

Martha Brown Menard, PhD, LMT Executive Director, Crocker Institute Kiawah Island, SC

David C. Miller, M.D. Indiana University Health Michigan City, IN

Paula L. Mitra Newberry, SC

Mary Beth Morrissey, PhD, MPH, JD President Collaborative for Palliative Care New York, NY

David Nagel, MD Gilmanton, NH

Carolyn Noel Webmaster, PAINS Project Volunteer Pain Advocate Owner, CAN Connect Services Jonesboro, GA

Kristen D. Ogden, Patient Advocate National Fibromyalgia & Chronic Pain Association Leaders Against Pain Action Network Prince George, VA

PAINS Project Kansas City, MO

Richard Payne, MD PAINS Medical Director John B. Francis Chair Center for Practical Bioethics Esther Colliflower Chair Duke University, School of Divinity

Angela Perry Independence, MO

Kalind Perry EMT-Basic Behavior Health Technician Independence, MO

Orvie Prewitt, Program Coordinator KC Regional Arthritis Center Saint Luke’s Hospital Kansas City, MO

Annette Prince, JD, LCSW Clinical Assistant Professor Director, Oklahoma Palliative Care Resource Center Department of Family Medicine Center Oklahoma City, OK

Project Lazarus Moravian Falls, NC

Maria Rago, PhD Aurora, IL

Dorreen Rardin, RN, BSN, CHPN Coordinator, Supportive Care Program Boone Hospital Center Columbia, MO

Reflex Sympathetic Dystrophy Syndrome Association Milford, CT

Jackie Rowles, CRNA Nurse Anesthesia Program Director Associate Professor of Nursing Marian University Indianapolis, IN

Dr. Joseph J. Ruane Medical Director Spine, Sport & Joint Center OhioHealth Corporation Columbus, OH

Sarah L. Schroer, LSCSW Transforming Care, LLC Overland Park, KS

Janice Lynch Schuster Independent Writer and Person with Chronic Pain Annapolis, MD

Roseann Seymour Laurelville, OH

Steven Simon, MD, RPh Overland Park, KS

Kim Spinelli MSN, APRN, BC, CNS Pain Management Clinical Nurse Specialist Memorial Hospital University of Colorado Health Colorado Springs, CO

Barbara St. Marie Eden Prairie, MN Duane Steward, DVM, MSIE, PhD Research Assistant Professor Center for Biomedical Informatics Texas A&M Health Science Center Round Rock, TX

Melissa Swanson Leader Against Pain National Fibromyalgia & Chronic Pain Association New Richmond, WI

Raymond C. Tait, PhD Professor, Department of Psychiatry Vice President, Research Saint Louis University St. Louis, MO

Erica J. Thiel Private Citizen, Rare Disease Advocate Gene Spotlight Foundation Juneau, WI

Donald Taylor, MD Comprehensive Pain Care, PC Pain Management and Addiction Medicine Marietta, GA

Texas Pain Society Austin, TX

The Collaborative for Palliative Care New York, NY

The Gerontological Society of America Washington, DC

The Pain Community Alamo, CA

Beverly E. Thorn, Ph.D., ABPP Board Certified in Clinical Health Psychology Professor of Psychology The University of Alabama Tuscaloosa, AL

Trust for America’s Health Washington, DC

Bob Twillman, Ph.D., FAPM Executive Director American Academy of Pain Management Lenexa, KS

US Pain Foundation Middletown, CT

Melissa Van Houten Indianapolis, IN

Jennifer Wagner Western Pain Society Eugene, OR

Lynn Webster, MD Past President, American Academy of Pain Medicine Salt Lake City, UT

David E. Weissman, MD Palliative Care Network of Wisconsin Member, Board of Directors Milwaukee, WI

Diana J. Wilkie, PhD, RN, FAAN Founder and Chairman, eNURSING llc Professor, College of Nursing, University of Florida Adjunct Professor, College of Nursing, University of Illinois at Chicago Park Ridge, IL

Wisconsin Pain Initiative Madison, WI

Lonnie Zeltzer, MD Director, Pediatric Pain and Palliative Care Program Division of Pediatric Hematology-Oncology Distinguished Professor of Pediatrics, Anesthesiology, Psychiatry and Biobehavioral Sciences David Geffen School of Medicine at UCLA Los Angeles, CA

CC: Sylvia Burwell, Secretary of HHS
Andrew Slavitt, Acting CMS Director