Tuesday, July 18, 2017 New National Academies Report on Pain Management and Opioids Recommends More Public Education, Reimbursement Models Supporting Nondrug Approaches to Pain Treatment The recommendations contained in a new National Academies of Sciences, Engineering, and Medicine (National Academies) report on pain management and the opioid crisis are wide-ranging, but a few may sound familiar to physical therapists (PTs), physical therapist assistants (PTAs), and anyone familiar with APTA's #ChoosePT campaign—namely, the need to support nonpharmacologic approaches to pain treatment through better reimbursement models, and the necessity of continued efforts to educate the public on effective alternatives to opioids. The positions on reimbursement and public education were among 21 recommendations included in the National Academies' report titled "Pain Management and the Opioid Epidemic," a comprehensive document that examines the opioid crisis from multiple perspectives. The overarching theme of the report: if America is serious about solving the opioid crisis, it's going to require work and change at nearly every level of health care, public policy, and even clinical education. In a chapter devoted to approaches to pain management, National Academies authors evaluate the current status of several nonpharmacologic approaches to pain, including acupuncture, manual therapies, and physical therapy. They assert that more research is needed on acupuncture, and that the evidence supporting chiropractic and osteopathic manipulation is "sparse." Physical therapy, they write, is in a slightly different situation: it's been proven to work, but an understanding of how it works, and guidelines for specific interventions, are harder to come by. "Despite the lack of strict guidelines or protocols for physical activity that may help patients with chronic pain, it appears that various types of physical activity can alleviate pain, including aerobic exercise, strength and flexibility training, walking, and manual therapy," authors write. "Exercise has been shown to be effective for treatment of many types and locations of pain, including fibromyalgia … back pain … osteoarthritis … whiplash-associated pain … and potentially even neuropathic pain." But there are “barriers to the successful use of exercise therapy for pain management," according to the report. These barriers can include patient-related factors such as lack of knowledge about exercise, but they are also within the health care system itself, including "the system's overly rigid focus on the biomedical model for pain, a lack of attention to or education about the value of exercise, a lack of supervision to ensure patient safety and comfort, and a lack of insurance coverage of the costs of exercise and physical therapy." Those barriers are among the reasons the report's recommendations include a call to facilitate reimbursement for comprehensive pain management by developing reimbursement models that "support evidence-based and cost-effective comprehensive pain management encompassing both pharmacologic and nonpharmacologic treatment modalities." The report also examined strategies for addressing the opioid epidemic through public education. In that section of the report, authors recount how the report's drafting committee "was struck particularly by the relative lack of attention to the impact of education of the general public … about risks and benefits of opioid therapy and the comparative effectiveness of opioid and nonopioid analgesics and nonpharmacological interventions." That gap prompted the committee to recommend that "the nation's public health leadership" including the surgeon general, US Centers for Disease Control and Prevention, and "heads of major foundations and professional organizations" evaluate and plan for a public education program on opioids and pain treatment. Both the need for better reimbursement models and the importance of public education on effective alternatives for pain treatment are at the center of APTA's public policy and public relations efforts. The association continues to advocate for more extensive direct access provisions, elimination of the Medicare therapy cap, and lower cost-sharing and copays for PT services, among other policy areas; and APTA's #ChoosePT campaign message has reached millions of Americans through a video public service announcement and the efforts of state chapters and individual APTA members. Among other recommendations included in the National Academies report: More investment in research to understand pain and opioid use disorder Improved reporting data on pain and opioid use Creation of "comprehensive pain education materials and curricula for health care providers" Expanded treatment for opioid use disorder and improved education on opioid use disorder for health care providers Additional studies aimed at a "thorough assessment of broad public health considerations" A full review of currently marketed or approved opioids "This plan aims to help the millions of people who suffer from chronic pain while reducing unnecessary opioid prescribing," said committee chair Richard Bonnie, MD, in a press release. "We also wanted to convey a clear message about the magnitude of the challenge. This epidemic took nearly 2 decades to develop, and it will take years to unravel."