ASRA Pain Medicine Update

Approved by the ASRA Board of Directors, November 16, 2016; updated May 12, 2021

The United States continues to face crises related to both chronic pain and addiction. Opioid overdoses continue to escalate, with over 81,000 overdoses occurring between May 2019 and May 2020 despite substantial decreases in opioid prescribing across the country since 2012. Illicit opioids, including fentanyl and its various derivatives, continue to play a major role in many of these deaths. In addition, the mental health and substance abuse issues that arose during the COVID-19 pandemic have exacerbated this situation.

Opioids should not be the first-line therapy for any type of pain management and particularly not for non-malignant pain. A patient-centered approach is essential; chronic opioid therapy should be reserved for patients with intractable chronic pain that is not adequately controlled with non-opioid treatment options, including other pharmacologic and non-pharmacologic therapies (including interventional pain procedures) where appropriate. Opioids should be prescribed at the lowest doses where clinical benefits outweigh risks. Ongoing surveillance for functional improvement, appropriate usage, and adverse effects (including aberrant behaviors) is critical, as are monitoring with random drug screening, random pill counts, and verification of prescription drug monitoring programs. Ideally, the lowest dose possible of these medications should be used to minimize side effects and reduce the likelihood of developing opioid use disorders (OUDs). In addition, an opioid exit strategy should be implemented to taper or discontinue opioids in situations where patients do not experience improvement in overall function.

Patient selection is also critical in choosing candidates for chronic opioid therapy; full opioid agonists should be avoided as much as possible in patients with a recent or active history of OUDs due to the inherent risk. Careful consideration and monitoring are also important for patients with underlying mental health disorders.

The current opioid crisis is the result of multiple contributing factors, including, but not limited to: 1) increased importation of illicit fentanyl and other opioids; 2) inadequate access to quality mental health care, particularly in the context of increased social isolation and mental health disorder exacerbations due to the COVID-19 pandemic; 3) a lack of knowledge among health care providers regarding how to safely and effectively minimize the misuse potential of opioid medications; 4) diversion of legitimately prescribed opioids; 5) the relative lack of effective treatments for chronic pain; 6) inadequate access to specialty addiction resources, including behavioral treatment, syringe exchange programs, and medication treatment for opioid use disorder (MOUD) with drugs such as buprenorphine, use of which the American Society of Regional Anesthesia and Pain Medicine (ASRA) strongly supports in both the outpatient and inpatient settings.

ASRA maintains the position that both pain and OUDs should be diagnosed and treated using comprehensive and multidisciplinary approaches and that specialty mental health and addiction resources, including MOUD, should be expanded to meet the growing demand. Anesthesiologists and pain physicians have an opportunity to make a significant impact and save lives.

Education, research, and advocacy are critical to accomplishing these goals.

• Education: Physicians and the public must continue to be educated on multimodal approaches to pain management; the safe use of opioids; tapering, if or when appropriate; and MOUD. The concurrent problems of pain and addiction have highlighted the need for education in implementation of opioid therapy, the use of non-opioid adjuvant medications for different pain conditions, diagnosis and treatment of opioid side effects, management of individuals exhibiting aberrant opioid behaviors, and implementation of risk evaluation and mitigation strategies, such as patient monitoring and drug screening. ASRA also advocates that naloxone should be made available to high-risk chronic pain patients and their family members as well as those with active OUDs. Members of the public and health care providers alike should be further educated on indications and appropriate use of naloxone to treat opioid overdose, as well as on local resources available to provide subspecialty care to patients with OUDs. ASRA continues to educate anesthesiologists and pain physicians regarding the appropriate use of buprenorphine in both inpatient and outpatient settings and believes that more practitioners of these specialties should employ this life-saving treatment when appropriate.
  
• Research: The promotion and support of research to demonstrate clinical therapeutic outcomes when using opioids and non-opioid therapeutics and interventions in the management of chronic pain are critical. While the efficacy of medication treatment for OUD is clear, further research into the potential use of MOUD medications for chronic pain would be extremely useful. Investigation into the factors leading to abuse, misuse, overdose, and aberrant behaviors would be beneficial as well. Lastly, well-designed studies are needed to evaluate non-opioid medications and treatment modalities that may serve as alternatives.
  
• Advocacy: Advocating for legislative and regulatory policies to allow pain patients to access opioids when appropriate while limiting inappropriate prescribing patterns, opioid abuse, and the flow of illicit drugs is essential. Key stakeholders must advocate for insurance coverage policies to allow access to non-opioid pain therapies, including but not limited to adjuvant pharmacological therapies, physical and occupational therapies, interventional pain management options, and mental health treatment. Expansion and improved insurance coverage of MOUD and other subspecialty addiction therapies are also crucial to provide treatment to patients with OUDs. ASRA advocates removing as many barriers to treatment as possible, such as the X-waiver requirement for buprenorphine prescribing.

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