Where it came from

The Comprehensive Addiction and Recovery Act of 2016 required the creation of a Pain Management Best Practices Inter-Agency Task Force, whose remit was to determine whether gaps in — or inconsistencies between — best practices for acute and chronic pain management existed, and to propose updates and recommendations.

It matters that this is an inter-agency federal product with a statutory basis rather than a professional society position or an industry document. It also matters that it was addressing both halves of the problem at once, which the National Academies had framed the previous year:

The ongoing opioid crisis lies at the intersection of two substantial public health challenges — reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications.

National Academies of Sciences, Engineering, and Medicine, 2017

The four recommendations this program is built on

The Task Force’s key recommendations for clinical best practice were that care should be:

1. Based on a biopsychosocial model of care. Pain is not only a sensory signal, and a model that treats it as one will fail in the population that actually has chronic pain.
2. Individualized and patient-centered. Which is the direct answer to dose thresholds.
3. Safer opioid stewardship through risk assessment based on patients’ medical, social and family history, to ensure safe and appropriate prescribing. Note the object: appropriate prescribing, not minimal prescribing.
4. Multidisciplinary, focused on the patient’s medical condition and comorbidities, and specifically elucidating behavioral health and psychological interventions.

Every component of this program maps to one of those four. Risk assessment to the third. Psychometrics and social determinants verification to the first and fourth. Metabolic determination and ProviderSynch to the second.

What the Task Force material says about screening, honestly

The same federal material that recommends screening also states its limits, and both halves belong on this page.

• Screening and monitoring are described as necessary to identify and reduce the risk of substance misuse, abuse and overdose, and to improve overall patient care.
• Urine drug tests can reveal drug use not reported by the patient and can inform treatment decisions — and the material states that, per an AHRQ systematic review, there is a lack of evidence demonstrating their effectiveness for risk mitigation during opioid prescribing, and that results can be misinterpreted and associated with practices that harm patients, such as stigmatization and inappropriate termination from care. See urine drug testing.
• Clinicians “must recognize the limits of screening tools in detecting prior or developing” substance use disorder or opioid use disorder.
• Screening should also cover long-term non-opioid use — NSAIDs causing renal, gastric and cardiac problems, and acetaminophen overuse causing liver injury, particularly where over-the-counter products combine them in ways patients are unaware of.

Barriers the Task Force identified

It is worth recording that the federal material identifies why recommended care does not happen, because a program that ignores those barriers will reproduce them. Named: clinical barriers (treatment accessibility, knowledge gaps, provider attitudes); health system barriers (cost and reimbursement); and patient barriers (stigma, attitudinal factors). It also notes that where access and cost are limiting, evidence-based low-cost scalable approaches delivered through telehealth and internet technologies can provide an effective alternative, with research suggesting brief digitally delivered treatments yield outcomes similar to traditional in-person psychological interventions for chronic pain.

That last finding is the direct rationale for delivering psychometrics electronically.