Dear President Obama:
I received news today of your $1.1 billion initiative to fight the nation's epidemic of opioid abuse.
No one questions the depth of the problems. What needs questioning is whether you are empowering the right professionals to find the solutions. Do we have a full quiver of approaches, practices and practitioners at our service?
Your plan focuses on monitoring and education. All good. There is commitment to making sure practitioners have "substance use treatment options." Sounding good too. Yet the only alternative options directly mentioned are more pharmaceuticals: "medication-assisted treatment." Bruprenorphene for treatment and naloxone for those over-dosing certainly have their value.
Yet nowhere in your fact-sheet can one find the terms "non-pharmacologic" or "integrative." I fear you are putting this $1.1-billion in the hands of those whose myopic focus on pharma fomented high levels of addiction in the first place. You are certainly aware of Albert Einstein's observation that "problems cannot be solved by for the same mind that created them."
Your plan presently misses a tremendous opportunity to move the nation toward a healthier path toward pain treatment. Consider opening hearts, minds and practices to the approaches recommended in a policy brief published by the Pain Action Alliance to Implement a National Strategy (PAINS). PAINS is a collaborative engagement of over 40 key stakeholders. The brief, from an interprofessional group of professionals with which I was involved, is entitled "Never Only Opioids: The Imperative for Early Integration of Non-Pharmacologic Approaches and Practitioners in the Treatment of Patients with Pain."
The basic idea is pretty simple. Create and support clinical models that always include non-pharmacologic methods -- otherwise known as integrative health and medicine. Pharma may be required. As early as possible introduce non-pharmacologic approaches. Work to wean them off.
The exception might seem to be when a person is in initial recovery from a major operation. Yet even in such cases, research is emerging that mindfulness practices, even in the form of listening to a simple meditative CD, can help limit drug needs and healing times. These low-cost approaches can reduce the need for addictive medications. Let's ramp up the use of these therapies.
The military has been dealing with opioid dependency more directly than the civilian population due to greater harm in that population. In Minnesota, early reports from the integrative Opioid Safety Initiative showed over 50 percent reduction in the use of high-dose pain killers in a veteran's population as reported in this paper. The strategy "emphasizes patient education... and complementary and alternative medicine practices such as acupuncture." Expand the model!
A chief witness and engine for the military's exploration of integrative methods is former U.S. Army Surgeon General Eric Schoomaker, M.D., Ph.D. (pictured). At a 2014 research conference, Schoomaker summarized his views in a keynote presentation entitled "The Imperative for Integrative Medicine in the Military." Four months later he took his views a step further at a Georgetown University symposium. He argued that this imperative also applies to civilian medicine. He's now working closely with the integrative health-focused Samueli Institute in a Chronic Pain Collaborative based on the Institute for Health Improvement's collaborative model. Use them as resources. Analyze their outcomes.
Good science is available. That's not the big issue in the failure to integrate. Take note that in 2014, the Joint Commission completed a review of the literature on pain treatment. This agency, charged with accrediting the vast majority of the nation's medical delivery organizations, subsequently issued a Clarification of the Pain Management Standard. The one page document first highlighted non-pharmacologic approaches like "acupuncture therapy, chiropractic therapy, massage therapy, osteopathic manipulative therapy, physical therapy" together with relaxation and behavioral therapy.
The Joint Commission then posted a red-flag. They urged clinicians to be aware of "the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse." One might safely discern that the concern was not with massage addiction or relaxation dependency, as pleasant as each may sound. The Joint Commission's directive moved the needle on pain care toward never only opioids. Even toward use these instead of opioids. Take this direction. Don't bury these options. Call them out. Elevate them. Point the research and clinical communities toward them.
The powerful Joint Commission is not the only significant national entity to take important steps in this direction. In November of 2015, the American Public Health Association (APHA) passed a position statement related to the epidemic. Their resolution, "Prevention and Intervention Strategies to Decrease Misuse of Prescription Pain Medications," included a call for "provider training programs on mental health, non-pharmacological pain treatment alternatives, substance abuse and overdose prevention." The APHA statement urged "pain prescription providers to be educated on identifying, and treating pain with alternative modalities and to coordinate pain management with complementary and integrative care providers."
President Obama, health and medicine in the United States remain sadly burdened by ignorance and prejudice regarding practitioners not considered part of allied health teams. Use this $1.1 billion to end the exclusion. Push all parties in pain treatment to practice the "non-discrimination in health care" that you wrote into the Affordable Care Act.
Parallel initiatives are underway at the state level. In Minnesota, professional organizations representing medical doctors, nurses and pharmacists recently announced a Joint Statement on Pain Management. They called for collaboration "using a multi-disciplinary approach to identify all treatment options including pharmacologic and non-pharmacologic modalities." They urged parties to "consider the integration of non-medication and multi-modality therapeutic approaches and set functional goals." Functional outcomes are what drove the popular movement for alternatives.
Oregon has moved a step further. Integrative treatment was recommended for implementation in the state's Coordinated Care Organizations (CCOs) though the Oregon Health Plan as of January 1, 2016. Kaiser Health News'"From Pills to Pins: Oregon is Changing How It Deals with Back Pain," describes a plan to reduce opioid addiction that includes Medicaid-covered chiropractors, acupuncturists and massage therapists. (Naturopathic physicians are already accredited to run CCOs in that state.) Let these be our teachers. Invest in exploring these models in Oregon.
President Obama, your election broke a historic barrier for the color of people. Eight years later, you can break the harmful exclusion of these professionals and practices. Do the right thing for people in pain. Ensure that we can access all the strategies that can help resolve the opioid epidemic.
Act affirmatively. Change the nation's therapeutic order in pain care. What a fine legacy -- for people in pain and for health care in the United States.