"Never Only Opioids" and the Joint Commission: toward a Conservative, Whole-system treatment standard for pain.

I view mainly as dumb luck the way I dodged the magic bullet of opioid dependence during my treatment for throat cancer 6 years ago. My doctors forewarned that radiation and chemotherapy together wreak havoc on throat tissues. I was sent home with a quart of pink liquid and a recommendation to use it preventively, just before I felt that pain might be coming on. They guaranteed I would need it. No one mentioned any other options for pain management.

I never needed the painkillers. One factor may be a cautionary view toward medication passed down in my natal family. Another may have been my use of multiple self-care and integrative methods and practitioners before, during, and after treatment. A friend who underwent a similar throat cancer treatment protocol who also took advantage of multiple integrative therapies had such pain that she needed ultimately to find her way to her new normal through a foggy tunnel of opioid dependency. My family joked that the grace that kept me from opioids could be chalked up to gross insensitivity.

Bullet-dodging in my episode of pain treatment did not end there. A year later, a neighbor shared that he was in horrible chronic joint pain linked to an athletic overuse injury. I mentioned the painkiller in the house. He thanked me and left with the bottle. He returned within hours, thrusting the quart back at me. He explained that he had a past addiction to pain medications. The proximity of excess leftover prescription opioids nearly pushed him off the wagon. Another magic bullet dodged.

Versions of this experience are reflected in the lives of tens of millions of individuals since 2000 when what was then called the Joint Commission on Accreditation of Healthcare Organizations passed pain standards for healthcare organizations in the United States. The standard focused on ensuring that pain was treated. Accreditation's quasi–police power pushed healthcare workers to err on the side of prescribing. Opioids and other painkillers became readily available. Dosing also tended toward the high end. Unused medications frequently ended up with unintended users. Pain treatment was characterized by active promotion, overprescription, unintended use, addiction, and no reference to options that might limit or obviate the need for painkillers.

In recent months, a pattern in pain policy is emerging that may help resolve the opioid epidemic in the United States that was triggered by the post-2000 standard. Nonpharmacological approaches and practitioners and the activities of individuals and consortia linked to the integrative health and medicine fields figure heavily in this shifting policy landscape. The remainder of this column reviews this activity over the past half-decade that is paving the way toward a whole-system, inclusive pain standard.

Without doubt, the most significant motivations for change are the dimensions of mortality and morbidity of the epidemic itself. Key data are captured in an October 2014 policy brief called “Never Only Opioids: The Imperative for Early Integration of Non-Pharmacological Approaches and Practitioners in the Treatment of Patients with Pain.” The 8-page paper notes that deaths associated with prescription opioids soared 400% in women and 265% in men in a decade; painkillers contribute to more than 17 000 deaths annually; NSAIDs and acetaminophen send another 80 000 each year to emergency rooms; problems are worse among members of the military; and painkillers of all kinds have become problematic street drugs, with multiple negative impacts on families and communities.[1]

This policy document and the associated recommendations were published through the Pain Action Alliance to Implement a National Strategy (PAINS), a national initiative involving more than 40 mainly pharmacy-oriented pain organizations. The coalition was conceived in the wake of the 2011 report from the Institute of Medicine (IOM) of the US National Academy of Sciences: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. The IOM committee, which included integrative pediatrician Lonnie Zelzer, MD, and a naturopathic physician-acupuncturist, Rick Marinelli, ND, MAOM, recommended an integrated, interdisciplinary approach. The committee noted, for instance, that “treatments can include medications, surgery, behavioral interventions, psychological counseling, rehabilitative and physical therapy, and complementary and alternative therapies.”[2]

An analysis I wrote in the Integrator Blog News and Reports found that the latter set of treatments—“complementary and alternative therapies”—merited mention in 15 segments of the IOM report.[3] However, the itemization as last, as above, reflects an overall limited integration of these approaches with the content and recommendations in the remainder of the IOM report. This dead-last positioning mirrored that of nonpharmacological approaches in a 2007 low back pain guideline from the American College of Physicians and the American Pain Society. Complementary and alternative medicine therapies made the list but as seventh among seven options for consideration. Even the Joint Commission's 2000 pain standard mentioned that some nonpharmacological approaches had evidence of value. Yet the message there, as in the subsequent documents, is that these approaches are not first-tier options. They are more of a last resort, eg, If all else fails, try acupuncture.

A more proactive approach toward complementary and alternative approaches and practitioners was simultaneously brewing in pain treatment practices in the US military. Like other early adopters of complementary and alternative medicine approaches such as entertainers and athletes, the military is performance-based and outcomes-driven. Soldiers, from pilots to ground troops, can be dangerously impaired via adverse medication effects. Nonpharmacological options had immediate appeal. Under former Chairman of the Joint Chiefs of Staff Admiral Michael Mullen, the military engaged integrative health and medicine leader Wayne Jonas, MD, and the Samueli Institute (Alexandria, Virginia) to create the 2010 publication entitled Total Force Fitness. The 132-page document elevated the stature of nonconventional options as essential components in the health of military personnel.

Revelations of opioid and other prescription drug abuse and dependence in soldiers returning from Iraq and Afghanistan further elevated the potential value of nonpharmacological approaches for these stakeholders. By 2012, 120 military facilities offered 275 complementary and alternative medicine programs producing more than 213 000 visits—not limited to pain conditions—for active duty military personnel. Former US Army Surgeon General Eric Schoomaker, MD, PhD, captured the proactive stance in a May 2014 keynote at the International Research Congress on Integrative Medicine and Health. There is, as Schoomaker titled his talk, “An Imperative for Integrative Medicine in the Military.” Imperative is a far cry from placement as last on a list or as an afterthought.

The translation into the civilian world of an affirmative, integrative model for pain treatment that promotes early use of nonpharmacological approaches found what might be considered a surprising ally in PAINS, the initiative that published “Never Only Opioids.” PAINS is the brainchild of the curiously-named Center for Practical Bioethics. In 2012, the US Senate investigated the Center along with six other nominally charitable organizations, including the Joint Commission, to determine whether these were unduly influenced by donations from pharmaceutical manufacturers. The Center was a reasonable target. Opioid manufacturer Purdue Pharma funded a chair at the Center held by PAINS founder Myra Christopher. Participating organizations span a vast network of pain interests from Purdue Pharma and the Lance Armstrong Foundation to the US Department of Health and Human Services, family medicine doctors, and the American Pain Society to the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) and the Academic Consortium for Complementary and Alternative Health Care (ACCAHC).

Despite the pharma backing and the presence of many oldline pain organizations, in early 2014 an inter-professional ACCAHC team received a go-ahead to develop a PAINS policy brief on the role of complementary and integrative approaches. The team included Martha Menard, PhD; Heather Tick, MD; Kevin Wilson, ND; William Meeker, DC, MPH; Arya Nielsen, PhD, LAc; and me. The paper's title echoes the “imperative” announced by Schoomaker for the military. The authors argue that two mounting evidence bases make their case for “early integration of non-pharmacologic approaches and practitioners.” The first is the harm caused by pain strategies that rely almost entirely on drugs. The other is the considerable expansion of research, much of it funded by the National Center for Complementary and Alternative Medicine of the US National Institutes of Health, demonstrating positive roles for multiple mind-body and other nonpharmacological approaches.

“Never Only Opioids” describes policy changes in the Affordable Care Act that indirectly support an affirmative embrace of non-pharmacologic options, even as the Act's funding of the 2011 IOM Blueprint directly engaged this shift in pain practice. The PAINS policy brief notes multiple components of the effort to shift the medical industry to a values-based system that supports a whole-systems approach: interprofessionalism, team care, patient-centered medical homes, accountable care, and even cost savings. Cited, for instance, is the IOM Blueprint's reference to a study of insured users of covered practitioners of licensed complementary and alternative medicine that found that users “had lower average expenditures that non-users” and that, notably for a system increasingly focusing on high-utilizers, “people who had the heaviest disease burdens accounted for the highest level of savings, an average of $1420.”[4]

The PAINS policy brief generated 13 recommendations for research funders, healthcare delivery, federal agencies, and health professions educators. Among these were increasing funding for studies that seek to limit use of painkillers through integrative means; bringing licensed integrative practitioners onto pain teams; requiring health professional education to include experiential programs in mind-body and self-care approaches that “elevate the idea of neuroplasticity (change the brain, change the pain) of the brain”; and promoting effort in the military toward “technology transfer” of successful programs for the civilian population.[5]

The effort to bring formerly last-resort therapies and practitioners into early integration that is advocated in the “Never Only Opioids” brief received powerful policy support on November 12, 2014. The Joint Commission, responding to a petition from integrative health and medicine interests, issued a clarification of its accreditation pain standard that significantly elevated the importance of nonpharmacological approaches.[6] Acupuncturist Arya Nielsen led a campaign to urge that the Joint Commission reconsider its 2000 pain standard. The effort was ultimately backed by the medical system in which she works, Mount Sinai Beth Israel, and 20 members of CAHCIM. The Joint Commission's clarification essentially placed nonpharmacological and pharmacological approaches on par. In addition, the clarified standard underscored that personnel in accredited inpatient and outpatient centers must ensure that potential adverse effects of pharmacological strategies are considered alongside positive values actively taken into consideration in decision making.

These actions bring no guarantee that a patient entering a hospital or outpatient facility with throat cancer, as I did in 2009, or any other pain-related condition will find nonpharmacological options on the menu. The clarified pain standard doesn't, for instance, have the most powerful of the Joint Commission's police power backing it. Yet at the same time, this series of actions relative to pain treatment in the last half decade in both civilian and military communities is clearly moving pain treatment toward an inclusive, conservative, whole-person standard.