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Pain Remains a Problem: Recommendations for Decision Makers to Support Alternative Therapies to Address Pain

By: Ryan Burdick

“How would you rate your pain on a scale of 1-10?” Beginning in the late 1990s, this question from your doctor became part of a national movement, “Pain is the Fifth Vital Sign,” aimed at assessing how pain impacts a patient’s life. For decades, patients reporting common pain conditions were routinely prescribed opioid medications such as OxyContin. Unfortunately, these prescription painkillers led to a generation of patients with opioid dependency, misuse, overdoses, and deaths.

In response to this crisis, some regions of the country focused on re-educating high prescribers or shutting down opioid ‘pill mills.’  Other regions implemented restrictions on access to prescription opioids, often without expanding coverage for rehabilitative services or alternative treatments to address a patient’s pain or its root causes. Throughout the country, a patchwork system of policies or programs have been adopted, like Prescription Drug Monitoring Programs, to reduce the harms from these addictive medications. However, a comprehensive strategy to address the treatment for common pain conditions for patients has yet to be enacted.

Currently, the opioid crisis is in the midst of an unprecedented wave of opioid-related overdoses and deaths, largely driven by illicit synthetic opioids such as fentanyl. Despite this reality, the U.S. Centers for Disease Control and Prevention reports that deaths involving prescription opioids account for around 15,000-20,000 fatalities annually, a figure that has remained relatively consistent for over a decade. Additional data show that although opioid prescriptions have declined nationally, these drugs continue to be prescribed at unhealthy levels, especially in assorted states and counties. Figure 1 shows this variation when looking at opioid dispensing rates of neighboring states and counties.

Source: (Centers for Disease Control and Prevention, 2024)

Clinical practice guidelines do not support the use of opioids for common pain conditions, such as back and neck pain. When viewing these regional differences, it appears that some communities continue to overutilize prescription opioids. This indicates a disparity in how pain care is delivered and likely leads to further downstream impacts for these communities, as the availability of these prescriptions increases so does the risk factor for misuse and potential addiction.

The $56 billion of opioid settlement funds offers an opportunity to tackle the root causes of the opioid crisis and its many consequences. So far, recommendations for these dollars have focused on prevention strategies, treatment, harm reduction and recovery programs. As jurisdictions support programs along this continuum of care, the following recommendations aim to support comprehensive primary prevention strategies that reduce unnecessary and excess opioid prescriptions.

Expanding Pain Alternatives as a Solution for Decision Makers

RAND Corporation published a series of recommendations designed for states and local municipalities to use their opioid settlement dollars to invest in the expansion and use of nonpharmacological therapies to reduce medically unnecessary opioid prescriptions for common pain conditions. Nonpharmacological therapies include but are not limited to spinal manipulation, acupuncture, mind-based therapy, and yoga. This publication, including the evidence to support alternative therapies for the treatment of pain, can be found at this link (Alternatives to Opioids). Below is a brief summary of the recommendations.

  1. Increase Awareness: Stakeholders across the healthcare sector should raise awareness of the benefits of nonpharmacological therapies through local or regional healthcare summits, provider education, and public announcements.
  2. Expand Medicaid Coverage: If needed, state leaders could use settlement funds to expand Medicaid coverage of nonpharmacological therapies, remove copayments, or other mechanisms to reduce cost-sharing to underserved populations. The settlement dollars could be used as the state portion of the local match, which would initiate the federal drawdown. Similar to how ARPA dollars were used for expanding health benefits.
  3. Enhance Equity of Access: Prioritize funding for Federally Qualified Health Centers (FQHCs) and other community health clinics, ensuring access to nonpharmacological therapies providers. Engage community leaders in conducting needs assessments and implementing programs to ensure that initiatives address the specific needs and challenges to better inform care pathways within a region.
  4. Support Nonclinical Interventions: Fund grants to provide evidence-based therapies like yoga and tai chi in community centers, local health departments, schools, and online platforms.
  5. Reduce Access Barriers: Allocate funds to analyze and correct barriers to providers of nonpharmacological therapies including regulatory changes, practitioner incentives, and transportation support for patients.
  6. Illuminate Care Pathway Gaps: Fund assessments of local hospital systems to align with pain management guidelines, prioritizing settings where opioid initiation is common.
  7. Integrate nonpharmacological therapies into opioid use disorder Treatment Facilities: Create pilot programs to add nonpharmacological therapies into treatment and analyze results.
  8. Build Infrastructure: Develop or enhance health technology such as clinical decision support tools that can improve clinical pathways to steer patients away from opioids.

Conclusion

Given the history of the crisis and the continued risks associated with opioid use, it is far past time to re-evaluate how pain is addressed within the current healthcare delivery system. As a nation, we must make substantial changes to achieve alignment with current medical guidelines for how patients are treated with common pain disorders, including expanding the use of nonpharmacological therapies. Opioid settlement dollars provide an opportunity to make the necessary changes so that patients will no longer receive an unnecessary opioid prescription more likely to cause harm than relief.

About the Author:

Ryan Burdick is a research consultant and co-author of the RAND Corporation’s publication “Alternatives to Opioids: A Missing Piece of the Strategy.” He has experience in healthcare policy at both local and federal levels. He completed a postdoctoral fellowship at Yale University’s School of Medicine, where he focused on analyzing musculoskeletal pain disorders in the U.S. healthcare system, including the U.S. Department of Veterans Affairs. Burdick holds a Doctor of Chiropractic (D.C.) degree from Cleveland University–Kansas City.