Patients with chronic pain continue to face barriers to care, including stigma, regulations limiting medication access, and shortages of pain-management specialists. But progress is being made on the regulatory front as the Federation of State Medical Boards (FSMB) recently adopted new recommendations for treating pain that include an emphasis on individualized, patient-centered care.
The FSMB House of Delegates adopted its “Strategies for Prescribing Opioids for the Management of Pain” document this spring, updating policy first adopted in 2017. Individual state medical boards are now deliberating how to integrate the new recommendations into their own policies.
The AMA was a member of the multidisciplinary workgroup that helped inform the FSMB strategies and strongly supports the update.
“The strategies accurately reflect that a course correction is necessary to balance the need for continued, appropriate oversight and patients’ access to evidence-based pain care,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in a letter to the FSMB prior to the vote by its delegates to adopt the strategies as policy.
The FSMB strategies represented a “clear call to the nation’s medical boards that patients with pain deserve greater care and compassion than recent history has afforded them,” Dr. Madara added.
Specifically, the AMA letter expressed support for:
- Providing clear guidance to boards and physicians about the need for individualized patient care decisions when evaluating, treating and managing care for patients with pain.
- Highlighting the importance of patient-physician shared decision-making when considering whether to initiate opioid therapy, taper therapy, or take measures to discontinue therapy.
- Emphasizing that evaluating the “success” of a treatment plan is multifaceted and could range from functional improvement to improvement in quality of life, as well as reductions in a patient’s decline.
- Recognizing that opioid therapy is only one possible facet of comprehensive pain management, but one that can play an important role in care.
As an orthopaedic trauma surgeon, AMA Board of Trustees Chair Michael Suk, MD, JD, MPH, MBA, noted during an AMA webinar (watch now) that he frequently cares for patients with pain and often engages with them to explore nonsurgical solutions such as medication or physical and cognitive behavioral therapies.
“How do I know what to do? Well, it depends on the needs of each patient,” said Dr. Suk, chair of the Musculoskeletal Institute at the Geisinger integrated health system in rural Pennsylvania. Geisinger is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
“It depends on the evidence and my own clinical experience—and sometimes it depends on the patient's insurance,” Dr. Suk added. “The one thing that it does not and should not be based on, is government interference or arbitrary restrictions.”
He told how physicians have reduced opioid prescribing by more than 50% over the last decade, but health insurance companies have not increased access to affordable nonopioid alternatives and, while the Centers for Disease Control and Prevention opposes numeric limits on prescriptions, nearly 40 states still have laws that restrict access to opioid therapy.
“These restrictions have harmed patients with chronic pain, those with cancer and in hospice, and those who have sickle cell disease,” said Dr. Suk. “The AMA has called for balance and individualized care decisions.”
During the webinar, FSMB CEO Humayun Chaudhry, DO, urged physicians to read the document and noted that it was written “with the readership of the practicing clinician and physician in mind.”
“There are lots of recommendations in there about how to thoughtfully consider patients who come in with pain,” Dr. Chaudhry explained.
“It doesn't mean that you don't use opioids,” he added. “It means you thoughtfully consider nonpharmacological approaches when appropriate—and when you think that opioids are appropriate, that you consider the patient’s past history and the context.”
Dr. Chaudhry emphasized that, regardless of whether physicians prescribe opioids, they need “to know what their state boards are thinking.”
It was also noted that, in the past, pain management was a source of health inequity.
“Racial bias has been shown to result in the undertreatment of pain in certain patient populations,” the guidelines say. “Clinicians should be aware of the impact of bias when evaluating patients with pain and strive to achieve equity fluency in care.”
Dr. Chaudhry explained that the guidelines seek “to make sure that anyone considering opioids be aware that the research shows that there is inequity and minoritized communities in particular have suffered not only related to prescribing, but also in relation to pain management.”
(The term “minoritized” refers to the process of historically relegating people to a subordinated status based on a dominant category intended to oppress groups based on a given social standing.)
The AMA believes that science, evidence and compassion must continue to guide patient care and policy change as the nation’s opioid epidemic evolves into a more dangerous and complicated illicit drug overdose epidemic. Learn more at the AMA’s End the Epidemic website.
Taking a nuanced approach
Sarvam TerKonda, MD, is a past chair of the FSMB board of directors and led the two-year effort to update the organization’s guidance on pain management.
A plastic and reconstructive surgeon, Dr. TerKonda said there were four reasons why the update was needed:
- Since the adoption of FSMB’s previous guidelines in 2017, new evidence has emerged about the risks and the benefits of prescribing opioid therapy—including the value of risk-mitigation strategies such as tapering and discontinuation to limit patient harm.
- Despite the significant drop in prescribing, the opioid overdose death epidemic has continued to accelerate—including more than 107,000 deaths in 2022. “Obviously, we know this was largely attributed to illicit and synthetic opioids, but this prompted a shift in our strategies to treat opioids,” Dr. TerKonda said.
- Chronic pain remains a significant public health hazard, experienced by 20% of U.S. adults.
- Certain patient groups, including older adults and those with cognitive impairments, are at high risk for pain but receive inadequate pain control.
“We recognized that the need for the updates was to advance current pain care and improve safe opioid prescribing,” Dr. TerKonda said.
Dr. Suk asked him if this also represented a change in thinking.
“The focus has shifted from this binary yes-or-no approach to a more nuanced understanding of pain management that really emphasizes individualized care,” Dr. TerKonda replied.
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The new guidelines “advocate for a more patient-centered approach, emphasizing that decisions regarding opioid prescriptions should be made in a collaborative manner between the physicians or clinicians and the patients,” he added. “This is really based upon the individual needs and circumstances.”
FSMB Board Member Sherif Zaafran, MD, is also president of the Texas Medical Board and he described how pain-management clinics in his state can apply to become a “Gold Designated Practice.” Clinics that receive this designation undergo an initial audit and then are exempt from further audits or inspections unless there is a formal complaint against them, they change location or they change ownership.
“I'm concerned about the balanced approach of making sure that we're regulating the inappropriate use of opioids while at the same time not disadvantaging patients who need to appropriately be treated with opioids for chronic pain—or for any type of pain for that matter,” said Dr. Zaafran an anesthesiologist who represents the Texas Medical Association in the AMA House of Delegates.
“One of the biggest concerns that I have is patients being moved from a regulated environment into an unregulated environment,” he added. “If you look at most overdose deaths, they happen in the unregulated environment where patients are still seeking treatment for pain that they may not be able to access from their physicians.”
He said two major areas of focus were ensuring that the legislature would not pass restrictive laws that would push patients into the unregulated environment and to create rules that ensured physicians that they would not be targeted by regulators if their treatment followed the guidelines.
“That took quite a bit of effort,” Dr. Zaafran said. “We empowered physicians who are in any type of setting, whether it be rural, urban, suburban or what have you, to be able to coordinate with other specialists using telehealth in a collaborative manner.”
Another focus has been to work with pharmacy boards to ensure that pharmacists do not change prescriptions for opioids or other medications without first consulting the prescribing physician.
Both Drs. Zaafran and Suk noted the harm that is caused by the stigma that is often attached to pain treatment.
“The AMA urges all state medical boards and state legislators to review their existing rules, and use the updated 2024 FSMB guidelines,” Dr. Suk said. “In doing so, it's our hope and our goal to help remove the stigma and harm that outdated, inappropriate rules and laws have caused.”
Drs. Chaudhry, TerKonda and Zaafran are all AMA members.
NOPAIN Act takes effect in January
Often, opioids have been the default treatment for pain because nonopioid therapies were often not covered by insurance or subject to regulatory barriers.
Speakers expressed optimism that the Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act, which takes effect in January, will bring change.
It directs the Centers for Medicare & Medicaid Services to provide separate payment for nonopioid treatments used to manage pain in the hospital outpatient departments and ambulatory surgery center settings.
The AMA Substance Use and Pain Care Task Force continues to advance evidence-based recommendations for policymakers and physicians to help end the nation’s drug-related overdose and death epidemic.
