This week, Real World Health Care continues our series on pain management with an interview with Bob Twillman, PhD, FAPM, Executive Director of the Academy of Integrative Pain Management. Dr. Twillman is responsible for overseeing federal and state pain policy developments and advocating for those supporting an integrative approach to pain management. He also serves as chair of the Prescription Monitoring Program Advisory Committee for the Kansas Board of Pharmacy. Dr. Twillman previously served as a faculty member at the University of Kansas School of Medicine, where he founded and directed the inpatient pain management program and was a co-founder of the hospital’s Palliative Care Team.
Improving People’s Lives
Real World Health Care: Can you describe the mission of the Academy of Integrative Pain Management?
Bob Twillman: Our mission is to improve the lives of people with pain by advancing a person-centered, integrative model of pain care through evidence-guided education, credentialing, and advocacy. In essence, we want to promote an integrative, multimodal, multidisciplinary approach to pain management because we believe such an approach is more effective and more cost-effective in treating all types of pain, both chronic and acute. Our educational opportunities teach clinicians how to provide this kind of care, and our advocacy efforts — which are unparalleled in the pain management sphere — promote policies that encourage provisions of this type of care.
Clinician Training & Challenges
RWHC: Why is it important for clinicians to be well-versed in integrative pain management?
BT: The traditional biomedical approach to pain management doesn’t always work well for a good number of people with pain. We know — and it’s been confirmed by the Institute of Medicine and in the recently-issued National Pain Strategy — that pain is a complex biopsychosocial phenomenon, and that an integrative approach is the only safe and sane way to care for people with pain. The only way to achieve the best possible pain control for every person with pain is to use an integrative approach that addresses all aspects of this complex phenomenon, as they play out for each individual person. There is no cookbook for pain care, and one size doesn’t even fit most, so we need to use an integrative approach that permits maximum flexibility in providing care.
RWHC: What are some of the biggest challenges that clinicians face in dealing with patients’ pain management issues?
BT: Undoubtedly, access to all the treatments we need in order to provide integrative pain care is our biggest challenge. Access to integrative non-pharmacological treatments such as acupuncture, massage therapy, biofeedback and others has never been good because insurance reimbursement is poor, causing people with pain to have to pay out of pocket for these treatments — something many of them can’t do. Adjunctive treatments such as physical therapy and behavioral health care might be more readily available, but they also are subject to inadequate insurance coverage that makes true access less than optimal. And now, even the medications that have been so ubiquitous as primary treatments of pain are under fire and both insurers and policymakers are restricting access to those as well. It’s really challenging to provide the kind of care that even key governmental agencies like the CDC have been calling for.
RWHC: How is the Academy addressing these challenges?
BT: AIPM continues to advocate for appropriate access to all of the treatments we need in order to provide comprehensive integrative pain care. Often, that means we have to battle inappropriate restrictions on pain medications, but we also advocate extensively for policies that promote improved access to non-pharmacological pain treatments. Recently, we have been advocating for enhanced Medicare and Medicaid coverage of integrative pain treatments, while also advocating for more opportunities to carry out Medicaid demonstration projects that we believe will show how much can be gained if those treatments were covered. And of course, we continue to educate clinicians about ways they can provide integrative pain care even if they don’t have a large multi-disciplinary staff and insurance coverage for all the treatments they need.
Pain Management Therapies
RWHC: What are the most promising non-pharmaceutical approaches for pain management and why are they important?
BT: Consider what the pain management experts at the Department of Defense and the Department of Veterans Affairs have listed as the five evidence-based, non-pharmaceutical approaches they think every current and former service member with chronic pain should be able to access: chiropractic and osteopathic manipulations, acupuncture, massage therapy, biofeedback, and yoga. And it’s important to note here, in follow up to my previous comment on inadequate coverage, that only some types of chiropractic and osteopathic manipulation are covered by Medicare, and only for some diagnoses. None of the rest of this list of five are covered.
Additionally, we know that many people with pain benefit from physical and occupational therapy and from behavioral health interventions. If we had full access with adequate insurance coverage for these treatments, we would be delighted. Being able to get these treatments for people with pain would mean that more of them would have less pain, better functioning in a number of areas, improved quality of life, and increased likelihood of being able to work. Plus, we would spend less money achieving those improved outcomes.
RWHC: How is the rising opioid addiction issue in America changing how clinicians address and treat their patients’ pain?
BT: For much of the past two decades, pain treatment has been primarily associated with opioid prescribing. While I think increased opioid prescribing was a well-intended attempt by the medical profession to provide better pain care, it may have been misguided due to lack of evidence, lack of access to alternatives, and the influence of a number of market forces and cultural beliefs. Now that this increased prescribing has been implicated in the parallel and sharp increase in overdose deaths involving prescription opioids, policymakers are extraordinarily active in pushing legislation and regulation intended to reduce excessive prescribing. Unfortunately, this is happening in the context of the non-pharmaceutical treatment access problems I outlined previously, without concomitant attempt to improve that access. All of that leaves primary care clinicians, who deliver the majority of pain care in this country, struggling to figure out what to do.
We are hearing from people with pain that some clinicians are responding by either setting an arbitrary dose limit for opioids, or by establishing policies that they will not prescribe opioids, regardless of the circumstances. That may be harming people who benefit from those medications, in service of benefitting those who use opioids inappropriately and in a harmful manner. I think it’s going to be a while before all of this shakes out and we can arrive at a balanced approach that maximizes the benefits and minimizes the harms for everyone.
Pharmaceutical Industry Efforts
RWHC: What should be the role of the pharmaceutical industry in addressing the rising opioid addiction issue in America? How can they work with clinicians and groups like the Academy?
BT: The pharmaceutical industry has been engaged in efforts to make their products safer, by developing abuse-deterrent opioids. These medications make it much harder to abuse prescription opioids by means of altering them to permit snorting or injecting the opioid medication. This is an important step, because it will protect people who misuse these medications — the vast majority of whom are not people with pain. If we are able to do that, then perhaps we won’t see as much of a reactionary backlash that causes people with a legitimate medical need for prescription opioids to have their prescriptions denied or taken away.
The industry can also help us by increasing funding for our education and advocacy efforts. We have so many needs for education — both for new clinicians who are now in school and for experienced clinicians who are in practice — that meeting the need is an enormous and extremely expensive task. Due to mandates for Risk Evaluation and Mitigation Strategies (REMS) education imposed by FDA, much of this funding has been redirected away from organizations like ours that can provide integrative pain management education — and without discernible benefit. We desperately need FDA to revise the REMS program blueprints so we can teach clinicians about more than just the pharmacology of opioids and so we can teach about non-pharmacological approaches to pain care. It’s really challenging for the industry to adhere to FDA mandates and to go beyond those, but we need to find a way to encourage that to happen.