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Could states be doing more to increase access to nonopioid and nonpharmacological approaches to management of chronic pain under Medicaid? The US Centers for Medicare and Medicaid Services (CMS) thinks so, and has issued guidance that outlines options and shares examples of some states' promising initiatives. The approaches are largely consistent with APTA's #ChoosePT opioid awareness campaign, which emphasizes the importance of patient access and choice in the treatment of pain.

The CMS information bulletin released in late February is anchored in the US Centers for Disease Control and Prevention's (CDC) guidelines for prescribing opioids for chronic pain, published in 2016. Those guidelines, which recommend nonopioid approaches including physical therapy as the preferred first-line treatment for noncancer chronic pain, have been increasingly acknowledged and adopted by state health care entities, and early reports are positive, according to CMS. The new CMS document is designed to help states understand possible avenues for incorporating programs that help support the CDC guidelines.

In outlining possibilities that could allow for the use of nonpharmacological approaches to chronic pain, CMS offers states a wide palette of mandatory and optional benefits, from more effective use of inpatient, outpatient, and health center services to expanded coverage for rehabilitative, physical therapy, and preventive services. The bulletin also offers home health benefits, special "demonstration" projects, and potential waivers as ways states could take creative steps to strengthen their nondrug offerings.

CMS also offers examples of states that have changed or extended their Medicaid coverage options, including Oregon, which expanded its list of Medicaid-covered services for uncomplicated back and neck pain to include physical therapy, cognitive behavioral therapy, and other services; and California, where a 14-county Medicaid program implemented an intensive prescriber education program on nonopioid options for pain management.

APTA has been engaged in the fight against opioid misuse in multiple ways. In addition to its flagship #ChoosePT opioid awareness campaign, the association has produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship. On the advocacy front, APTA continues to meet with legislators and agency representatives to address the opioid crisis, and comments on a range of topics, including a federal Pain Management Best Practices Inter-Agency Task Force draft report. Additionally, a recent formal partnership between APTA and the Department of Veterans Affairs includes collaboration to promote veterans' access to nopharmacologic approaches to pain management.

"Providers and beneficiaries need access to effective therapy for chronic pain," CMS writes. "A multidisciplinary approach…that incorporates nonopioid pharmacologic and nonpharmacologic therapies, well-communicated treatment goals and expectations, and a careful consideration of the benefits and risks of available treatment options is the most appropriate approach for most patients and has the potential to lead to more appropriate prescribing of opioids."


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