To update its controversial 2016 guidelines for how to treat the millions of Americans living with pain, the Centers for Disease Control and Prevention (CDC) has been doing its homework. The agency has overseen a thorough review of the evidence and is still gathering input from clinicians, scientists, people with pain, and their families.
Unfortunately, the CDC’s enormous effort may turn out to be a bridge to nowhere for most Americans living with chronic pain. The final guidelines will likely recommend a comprehensive set of options to address pain, many of which will be available to only a few Americans. That’s why the US Department of Health and Human Services should launch an equally ambitious effort to ensure that the CDC’s new guidelines are more than wishful thinking.
The CDC began working on an update to its pain guidelines two years after they were published, largely because of criticism that the guidelines advocated less use of opioids but provided fews for patients living with pain and that they were not always applied correctly. The agency’s first step was to commission the Agency for Healthcare Research and Quality to systematically review new evidence on opioids, complementary and alternative treatments for pain, and non-opioid painkillers. AHRQ’s review found that a number of complementary and alternative therapies can decrease pain — and even improve function — as much as pain medications do, with significantly fewer risks, for common pain conditions.
The CDC then convened an Opioid Work Group comprised of patients, clinicians, and subject matter experts who met 11 times over nine months to review initials draft of a new set of guidelines for opioid prescribing that addresses both acute and chronic pain. Between July 2020 and July 2021, the CDC provided the public with four opportunities to comment on the guidelines, reviewed comments, and incorporated draft edits.
The CDC released its comprehensive draft on February 10, 2022. While it still recommends using opioids only when needed, it removes upper limits for prescription opioids, and emphasizes a patient-centric approach. It also goes much further than the 2016 guidelines by meticulously spelling out alternative treatments to opioids.
For patients living with chronic pain, for example, the agency emphasizes the role of non-invasive, non-drug treatments such as physical therapy, psychological therapies, and mind-body practices, including yoga, tai-chi, and relaxation techniques. The draft guidelines also support acupuncture, laser therapy, and manual therapies like chiropractic care and massage.
The CDC’s latest draft underwent peer review and a 60-day public comment period that ended April 11. The comments are currently being evaluated.
The early reviews are positive. A colleague of ours at Johns Hopkins, Marie Hanna, who directs the Perioperative Pain Clinic at the university’s School of Medicine, told us, “These guidelines set a precedent by emphasizing the evidence supporting non-pharmacological, non-invasive therapies for pain — things that have been used to relieve suffering and improve quality of life in other countries for years.”
Yet the thoroughness of the CDC’s approach is exposing the weaknesses and inequity of the US health care system. Alternative treatments for pain may work, but they are hard to get. A January 2022 study in JAMA Network Open found that at least half of insurers do not offer any coverage for acupuncture and, when coverage exists, it is spotty at best. Medicare will cover acupuncture for chronic low back pain, but it does not pay for other uses recommended by the draft CDC guidelines, such as neck pain and fibromyalgia. Massage is not covered by Medicare Part A or B for any pain or any other condition, and coverage is virtually non-existent for the emerging pain treatments that the CDC draft guidelines support, such as laser therapy for pain.
On top of poor or nonexistent insurance coverage, patients must have the time, transportation, child care, and access to specialized clinics that offer alternative pain-control approaches. Yet the people least likely to be in a social and economic position to access high-quality treatment for pain are the most likely to need it. A year after a motor vehicle accident, individuals from lower socioeconomic status neighborhoods have significantly higher pain levels. Similarly, patients with lower education levels are 2.8 times as likely to develop chronic knee pain after knee surgery compared to those with higher education levels. There are also significant gaps in access to comprehensive pain treatment by race and ethnicity.
These circumstances create the risk that the CDC guidelines will engender even more unfairness in the treatment of pain: alternative, safer, and effective therapies for a small group of Americans fortunate enough to access them, and undertreatment — or more opioids than necessary — for everyone else. Avoiding this scenario should be a top priority.
Step one to that end is a framework to improve insurance coverage. It’s not enough for insurers to send clinicians alerts about excessive prescribing and to counsel patients to use medications sparingly. Insurers should facilitate access to effective and appropriate alternative treatments for pain. Medicare and Medicaid can lead the way by establishing new and expanded coverage standards, and private insurers should commit to the following suit.
Step two is for the federal government to devote funding to lower barriers to accessing evidence-based opioid alternatives through transportation vouchers, subsidized childcare in treatment centers, start-up resources for new integrative pain centers in regions where none exist, and new fellowship programs to train more physicians in the science of comprehensive pain treatment.
Physicians and other health professionals should learn about the new options in order to make effective referrals.
There should be accountability for delivering effective treatments to patients living with chronic pain, with a public facing dashboard, akin to the one Hopkins created for Covid-19 that breaks down access to alternative therapies by geography, gender, race, and ethnicity to ensure health equity.
As important as it is to have a comprehensive set of recommendations for the treatment of patients with pain, it’s even more important is to bring these recommendations to reality.
Shravani Durbhakula is a pain physician and anesthesiologist, an assistant professor of pain medicine and anesthesiology at the Johns Hopkins School of Medicine, director of the school’s Pain Course, and creator of PainRounds.org. Joshua Sharfstein is professor of the practice in health policy and management at the Johns Hopkins Bloomberg School of Public Health and former principal deputy commissioner of the US Food and Drug Administration. The views expressed here are theirs and do not necessarily represent those of their employers.