AMA Advocacy Insights webinar series: Patients with pain need individualized care: How policy is shifting

It is clear that a one-size-fits-all approach to caring for patients with pain is not a prudent way to manage care. National policymakers are taking note: the Federation of State Medical Boards recently adopted revisions to its recommendations relating to opioids and pain care at its April 2024 annual meeting that focus on individualized, patient-centered care. The AMA strongly supports the update.

Watch this Advocacy Insights webinar to hear about:

• The new guidelines and how they were updated
• Recommendations and expectations for medical boards
• How medical boards are addressing access to treatment for patients with pain

Moderator

• Michael Suk, MD, JD, MPH, MBA, chair, AMA Board of Trustees

Speakers

• Humayun Chaudhry, DO, president and CEO, Federation of State Medical Boards
• Sarvam TerKonda, MD, past chair, Federation of State Medical Boards
• Sherif Zaafran, MD, board member, Federation of State Medical Boards

Dr. Suk: Hello and thank you for joining us this afternoon for our latest in the AMA Advocacy Insights webinar series. I'm Dr. Michael Suk, chair of the American Medical Association and an orthopedic surgeon specializing in orthopedic trauma, hailing from Pennsylvania. 

It's my pleasure to be your host today for this really important discussion. Today's webinar focuses on pain, more specifically emphasizing the importance of ensuring that every patient receives individualized care for their pain. 

As an orthopedic surgeon and one specializing in orthopedic trauma, I deal with pain in patients who are suffering from conditions that cause them pain all the time. And we also try—and within my specialty to try to engage patients in ways that can avoid surgery, and oftentimes in different ways to mitigate their pain symptoms. 

Sometimes this includes things like physical therapy or cognitive behavioral therapy, and oftentimes medication as well. And sometimes those therapies work great on their own or in combination. Sometimes opioid therapy is helpful. And if surgery is needed, some or all of those therapies might be needed. 

How do I know what to do? Well, it depends on the needs of each patient. It depends on the evidence and my own clinical experience. And sometimes it depends on the patient's insurance. 

The one thing that it does not and should not be based on is government interference or arbitrary restrictions. That might seem obvious, but even though physicians have reduced opioid prescribing by more than 50% over the last decade, health insurance companies have not increased access to affordable, non-opioid alternatives. 

Even though the CDC now opposes numeric limits on prescriptions, nearly 40 states 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.

The AMA has called for balanced and individualized care decisions, and we have supported efforts in states and in Congress for such bills, such as the NOPAIN Act, which requires Medicare to pay for non-opioid alternatives. It's disappointing that it takes legislative advocacy to force payers to increase pain care options for patients, but the AMA will never stop fighting for these patients and access to affordable care options. 

And we're also thankful for the leadership of the Federation of State Medical Boards to recognize the need for that balance as well. As a surgeon, these guidelines reflect how I try to practice. Treat every patient as an individual, engage in shared decision making about the benefits and risks of all treatments, and work together to maintain or improve function and outcomes. 

Joining me today are three physicians who will detail just how the FSMB accomplished this. Humayun Chaudhry, DO, president and CEO of the Federation of State Medical Boards; Sarvam TerKonda, MD, past chair, Federation of State Medical Boards; Sherif Zaafran, MD, board member, Federation of State Medical Boards. 

I want to make sure that we have enough time to discuss these important issues and answer your questions, so I'm going to get started right away and just jump in with a couple of comments and questions. Dr. TerKonda, you were chair of the workgroup developing these new recommendations. Can you share with us why these new updates were needed? 

Dr. TerKonda: Well, thank you, Dr. Suk. And I'd also like to thank the American Medical Association for placing this webinar, and it's an honor to be here with the experts on the panel. 

In April of 2024, the Federation of State Medical Boards House of Delegates adopted this guidance document called Strategies for Prescribing Opioids for the Management of Pain. And there were essentially four reasons why we needed this update. 

Number one, the new emerging evidence. Since the adoption of our previous guidelines in 2017, new evidence had emerged about the risks and the benefits of prescribing opioid therapy. This included the value of risk mitigation strategies such as tapering and discontinuation to limit patient harm. 

The second reason was the accelerating opioid epidemic we all were exposed to. Despite a decrease in the overall opioid prescriptions by over 44% from 2011 to 2020, the overdose deaths continued to rise to over 107,000 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. 

The third reason was the prevalence of chronic pain. Unfortunately, in the United States, chronic pain remains a significant public health hazard with one in five adults in the United States experiencing it. And the fourth reason was we had inadequate pain treatment. Certain patient groups, including older adults and those with cognitive impairments, may be at high risk for pain, but had inadequate pain control. 

The FSMB recognized that the need for the updates was to really advance the current pain care and improve safe opioid prescribing. So those were really the overall reasons for updates. 

Dr. Suk: Thanks for that. And it's interesting because so much of the discussion of treating patients with pain, especially among policymakers, has been really focused on a yes or no. Do we prescribe, don't we prescribe or how much do we prescribe? How would—how would you describe these recommendations as different from just a pure quantity type of approach? 

Dr. TerKonda: Well, you're right. The focus has shifted from this binary yes or no approach to a more kind of nuanced understanding of pain management that really emphasizes individualized care. And I think the current guidelines that we have—we just had this past year 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. This is really based upon the individual needs and circumstances. 

We also realized there was a need for a more comprehensive treatment plan, including non-opioid and nonpharmacologic therapies. And we wanted to also emphasize the need for a better method for monitoring and providing risk assessment to the patient. So those are really the basic reasons that we've seen this shift from this yes or no approach to opioid therapy to a more nuanced approach. 

Dr. Suk: Well, that's very helpful, and thanks for sharing that information. 

You were a member of the workgroup, and you were also a member of the Texas Medical Board. What's your perspective on why these recommendations are important? And why are they needed now? 

Dr. Zaafran: Thank you for inviting me and being part of this panel. Appreciate the AMA helping take the lead on a very important issue. So as president of the Texas Medical Board, one of the things that, of course, I'm concerned about is 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 for opioids—or with opioids for chronic pain, or for any type of pain, for that matter. 

One of the biggest concerns that I have is patients being moved from a regulated environment into an unregulated environment. And if you look at most overdose deaths that are out there, it actually happens in the unregulated environment where patients are still seeking treatment for pain that they may not be able to access from their physicians. 

And in that unregulated environment, they may think that they're taking an oxycodone tablet. But as we know, in many instances these may be laced with things like fentanyl or other entities that cause overdose deaths. 

So one of the biggest things that we've been focusing on is making sure that patients have appropriate access to care and that physicians don't feel like they're being targeted when appropriately managing and treating pain. And that took on quite a bit of effort. We had to make sure that the legislature was going to pass laws that were not going to unintentionally create an environment where patients were being pushed into an unregulated environment. 

And at the same time, we needed to look and create rules to make sure that physicians felt that they were—if doing the right thing based on the guidelines that we have here were not going to be targeted. And a little bit later on, we can talk about some of the specific things and how we did that in the Texas Medical Board. 

Dr. Suk: No, I think that's great additional information. Your perspective as someone who's on the State Medical Board I think is really important. Going with that theme, how can medical boards and state medical associations together work to ensure to find the balance of caring for patients with pain and the fear that physicians have for treating them in a manner that may make them a target? And more importantly, how do we not over-regulate and provide appropriate guidelines? 

Dr. Zaafran: Yeah. So as I had briefly mentioned earlier on, there is the first step of making sure that legislators don't unintentionally—with the goal of appropriately wanting to make sure that they address the opioid epidemic are not passing rules and laws that can actually have those unintended effects. 

So we actually worked with the state legislature several years ago to pass some laws that actually gave the Medical Board some latitude in helping create rules that help govern how we define acute pain, chronic pain, et cetera, and how we govern and regulate that process. Because as we know, it's not a one-size-fits-all, and we've got to make sure that we have that flexibility in managing the process. 

The other thing that we did is I put together a task force and a stakeholder group that included the Texas Medical Association, the Texas Pain Society, insurers in the state of Texas because the payers, of course, play a big role in that. This was before the NOPAIN Act where the federal government actually mandated for the payment of non-opioid modalities. And actually, we had patients involved, or the public involved in the stakeholder group. 

And the idea behind this was to look at solutions, not identifying problems. But we wanted to make sure that we weren't just hearing complaints, but we were going to come up with ideas of how to actually address this. And after about a year and a half of having several stakeholder meetings, we came up with a gold rule in the state of Texas. 

And that law—that rule, which, in Texas, a rule from the medical board has the force of law on it—created a mechanism where if a group of providers that included a physician, which may have been a primary care physician, along with a consulting chronic pain physician, along with other entities like behavioral therapists and other type of—other types of therapists that would help in a multi-modal type of approach—not only multi-modal, but multi-disciplinary—if they had that type of structure in place and actually operated a proper pain management clinic which is overseen by the medical board, then we would do something called a gold rule pass, which essentially meant that after the initial audit, we would hold them harmless from any type of audit for the next five years, so long as they actually didn't have a formal complaint that came along the way. 

And the reason we did that is we wanted to make sure that, number 1, 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 or telemedicine in a virtual manner and in a collaborative manner, and with that be able to actually treat a chronic pain patient in a manner that follows these guidelines. Again, multi-modal, multi-disciplinary-type approach. 

We think that's working. We've been telegraphing that to our physicians so that we could encourage them to be part of—to be part of this process. And so far, I think it's been working. 

The other thing that we've been doing is working with the pharmacy board, making sure that they don't arbitrarily just start changing medications, especially opioids, without consulting with the physicians. Because again, if you limit what a patient can take, especially a chronic pain patient, again, that forces them to potentially go into that unregulated environment and kind of defeat the purpose of a lot of what we're doing. 

So that's been our starting process. I think it's been working. But it has been a collaborative effort with all the different stakeholders in the medical community as well as in the nonmedical community. 

Dr. Suk: No, that's very helpful. And your experience, certainly in Texas I think, is going to educate many others with the experience that you have there. Dr. Chaudhry, you're the president and CEO currently of the FSMB, and so maybe you can talk a little bit about how FSMB is helping to implement some of these recommendations. 

Dr. Chaudhry: Well, thank you very much, Dr. Suk. And thank you to the AMA for bringing my colleagues and I together for this important webinar. It's an important topic, as you know, and it's a big problem in our nation. 

So I think it's important to note that the FSMB, the Federation of State Medical Boards, our role is to provide guidance and resources and to share best practices with our state medical licensing boards. And two years ago when—two years before this policy was adopted—actually, Dr. TerKonda gets the credit. He was the chair of the FSMB and felt that we needed to review our policies. Our last policy was adopted in 2017, eight years before—seven years before. 

So we took two years to thoughtfully put this together. We included state medical board representatives as well as colleagues from many other organizations, including the AMA. 

And that was important because when it was ultimately presented to our House of Delegates earlier this year, it was adopted. And there was a lot of good discussion, good feedback. But ultimately, where the state boards are now is they're reviewing this document and considering how to adopt and/or adapt the document for their use. 

Dr. Suk: I appreciate that additional information. It's good that there's forward progress. Let me just ask you. In addition to the areas highlighted by Drs. TerKonda and Zaafran, why is it important for physicians and medical societies to read the recommendations in depth? And how else can they work effectively with their state medical boards to help implement some of these recommendations? 

Dr. Chaudhry: Well, that's a great question, Dr. Suk. I think any physician would be forgiven for thinking that a policy that comes out of the Federation of State Medical Boards might be a policy for state licensing boards. But actually, if you read the document, it's not overly long, but it's also with the readership of the practicing clinician and physician in mind. So there are lots of recommendations in there about how to thoughtfully consider patients who come in with pain. 

It doesn't mean that you don't use opioids. It means you thoughtfully consider nonpharmacological approaches when appropriate. And when you think that opioids are appropriate, that you consider the past history and the context. And I think that kind of review and reminder, I think, would be helpful to any physician, not just those who engage in pain management, to understand what the state boards are thinking. 

And as I said, a number of the state boards are in the process of reviewing the document. I think every practicing physician, whether or not they prescribe opioids, needs to know what their state boards are thinking because it's an issue where there has been some updated understanding and research that Dr. TerKonda and Dr. Zaafran alluded to, which informed what the policy ultimately says. 

Dr. Suk: No, thank you for that. We have—and I appreciate the opening comments and the indulgence of my initial set of questions here. There are 225 participants on the call, which is really fantastic for all of us. A number of questions that are in the chat. I'm going to take a moment to cultivate those. 

But prior to jumping into some of those, maybe I'll just ask Dr. TerKonda one of the—a pre-submitted question that was done from some of the audience members earlier. Maybe you can talk about some of the methods that are used—that are used successfully to coordinate pain management between primary care specialists and ED physicians. Anything from your experience where you've seen a successful model to try to coordinate that care. 

Dr. TerKonda: So Dr. Suk, I'm like you. I'm a surgeon practicing. So I think as a clinician, we need to take a holistic view of the patients. We may have our specialties, but we need to be able to recognize anyone that requires pain management therapy, and that means reaching out to the appropriate multi-disciplinary approach. 

So as we said, we want to really understand pain and how to manage pain, not in our own specialty, but in general. So the current guidelines really advocated for a more collaborative approach between the care team and that patient. 

And I think making this—giving this holistic view provides access to the appropriate modalities, whether it's opioid therapy or non-opioid therapy, nonpharmacologic therapy, making sure there's behavioral modifications that are appropriate for the patient. So I think having that understanding and being able to refer that patient appropriately is important. 

And I think that's where the guidelines come in. For someone such as us who are surgeons, we may not deal with chronic pain, but we have that acute pain knowledge. But when we see those patients that need further help, we can get them to the appropriate specialists.

Dr. Suk: I appreciate that, and I agree with you. I think the coordination of care is key. New modalities and new pathways, I think, will ultimately start to come out of these multi-modal approaches that require multi-specialty inputs. 

Dr. Chaudhry, let me ask you a question about just populations in general. Are the concerns of populations who suffered pain management and equities addressed with some of these new rules? It's an equity question. 

Dr. Chaudhry: Absolutely, Dr. Suk. In fact, I think Dr. TerKonda touched on that a little bit in his remarks. While the opioid epidemic has evolved, as we all know, it's no longer just overprescribing or inappropriate prescribing of prescription opioids, long-acting and extended release. It's also illicit and synthetic opioids that are out there as well. 

But prescribing is still an important component. And so, part of the guidelines, what they try to do is to make sure that anyone considering opioids be aware that the research shows that there is a inequity. And minoritized communities in particular have suffered, not only related to prescribing, but also in relation to pain management. And so that is a key component of this. 

We benefited on the workgroup, I should say, by not only having colleagues from the AMA and the AOA, but also from the CDC, input from SAMHSA, the American Society of Addiction Medicine. Again, a lot has happened in the last several years that has better informed our thinking. And that's actually another reason why physicians who are out there prescribing or dealing with patients with pain may want to look at our document to better understand the current thinking of experts from around the world and around the country as they try to manage this. 

Dr. Suk: Thanks. And Sherif, let me ask you a question, going back a little bit to our conversation with Sarv. In your experience, what do you think is the best approach to shared decision making when it comes to pain management? What are your thoughts on that? 

Dr. Zaafran: Well, I mean, again, it's a matter of getting the stakeholders who are involved actually helping to manage that patient's pain. Right now, we have a system or a mechanism where primary care physicians feel that they are the pain physicians of many of those patients, and they are not equipped or don't necessarily feel like they're equipped, whether it's by compensation for time or for other modalities that are out there to help manage patients' pain. 

You have chronic pain physicians who may not necessarily be in areas where some of those patients are. Again, they may be in urban or suburban areas and not necessarily in rural areas. And you also have a finite number of other specialists—behavioral therapists, physical therapy guys that are out there who really should be involved in that process. 

And you had a mechanism of the multi-modal approach, whether it be music therapy, other modalities that were never compensated by insurance. And so even up until recently, it's easier to get insurance to pay for opioid medications than it is for them to pay for non-opioid medications. 

So the first part is, number 1, making sure that we have rules and regulations that allow and empower physicians to be able to manage these patients in a way that they feel comfortable in doing so. But the other part is leveraging the technology that's out there, whether it's telehealth or telemedicine, to bring together all these folks, regardless of geography, to help take care of these patients where they're at. 

To take a chronic pain—a chronic pain patient and ask them to drive 100 miles to go see a specialist who can help manage their pain is simply not realistic. So they're going to go to the default, which is the easy way of treating pain, which is by opioids, which is not necessarily the best way of treating it. It's one part of a multi-modal approach. 

The other part that we wanted to do is also retiring physicians. A physician that was managing a patient for chronic pain who all of a sudden retired, and that patient now needs somebody to help manage their pain. And the fear that patients have—sorry, the fear that physicians have in taking on a difficult patient—not difficult because the patient's difficult, but their disease and their illness may have taken years in order to be managed in a way that was appropriate. 

And all of a sudden, they feel like they may be targeted because they're starting them on medications that would look like it's way beyond what the norm is, however way we define the norm. Making sure that that transition is done in a seamless way so that not only insurance companies, but physicians don't tell a patient, by the way, you've been on these medications for years and years and years, but you know what? We're going to have to start you from scratch again. We're going to have to start you from ground zero. 

And in that transition, in starting from ground zero, that patient is going to experience significant discomfort. And they may, again, go to the unregulated environment to bridge that gap. 

So we've got to make sure that that transition for patients when physicians are no longer available for them is something that is done in a seamless way. We've got to create an environment where physicians can collaborate, and nonphysicians also can collaborate in a way that empowers them to treat those patients in a multi-modal and a multi-disciplinary way. And as the federal government has just recently done, make sure that the payers are required to pay for best practices, which we are defining, again, as a multi-modal and a multi-disciplinary way. 

All these factors have to come together in a way to do something that is very complex. A lot of the problems that we have is when something is complex and difficult, we try to solve it with an easy answer, and there are no easy answers. It's taken years for us to get to a mechanism that hopefully will start that process. But it is a collaborative effort, and we've got to continue empowering all of us to be able to work together to help manage these patients. 

Dr. Suk: Thanks, Sherif. Hank, maybe I'll go back to you, and this is maybe something that you both and Sherif can handle together. It sounds like a generic question, but it's legitimate. What role does the federal government have in regulating pain? We understand what happens in the state licensing board, the state medical board, but why the federal government? 

Dr. Chaudhry: Well, they play a critical role in the regulation of a lot of this, but the FSMB itself does not get involved in the reimbursement aspects of it. We're focused on the state licensing aspect. The primary purpose of a state medical board is to protect the public, but also to assure that quality health care is delivered. 

So from our perspective, agencies like the CDC, SAMHSA, DEA play a very important role in giving us the research, giving us information, and partnering with us so that we can develop thoughtful guidance. I think from our perspective, that's the key role, but there are obviously other aspects to the management of pain. 

I think Sherif touched on some of these related to reimbursement, for example, of the nonpharmacological therapies, for example. I mean, it's easy to prescribe massage treatments or exercise or osteopathic manipulative treatment, but are they covered to the extent that could be helpful? 

I think in the seven years since our previous policy, there's been a greater awareness of social determinants of health and that not everyone has the same ability or insurance coverage to be able to get the care that they need. So what we call for is a more thoughtful response. 

Dr. Suk: Thanks. Sarv, any thoughts on that? 

Dr. TerKonda: No, I think Hank brought up the most important points, and Sherif also stated that from a federal government standpoint, making sure that all modalities of therapy are available to the patient, not just a single coverage of opioids or making that the easiest option. I mean, there really has to be a more comprehensive approach. And that's what the federal government, I think, can help with, is to provide coverage for that. 

And as Hank said, FSMB does not get involved in the payment process or any suggestions for payment. We're really looking at licensure and how best practices can be spread among our state boards to the physicians. 

Dr. Chaudhry: I'll also mention, if I may, Dr. Suk, that there's an enforcement piece from the federal side with the DEA. There is a concern about diversion. Where are some of these sources of illicit opioids in particular coming from? So there is a important role for the federal government, I would say, to play to try to mitigate that at that end. 

What we're focused on, though, is with prescribing and providing care and compassion. Patients with pain deserve as much care and compassion as patients with any other complex medical condition. 

Dr. Suk: Yeah. And sticking with the federal government theme a little bit, I alluded to the NOPAIN Act, which is due to be enacted in—or begin to—enforced in January 2025. This ultimately has to do with payment for non-opioid alternatives, which many of us hope will open the door to making much more acceptable, and certainly from a payment perspective, a coverage perspective, patients who want to seek alternatives other than opioids. I'll open it to any of the three of you if you have any thoughts or comments, hope, fear, anything like that associated with what might be turning around the corner here. 

Dr. Zaafran: Yeah. You know, we used to have an HHS task force on closing the gaps in managing pain. I actually served on that task force several years ago. And one of the recommendations actually was, number one, aligning all the different entities from the state lawmakers and federal lawmakers, as well as regulatory agencies and other providers. 

The key thing with all this, though, is it's not a matter of whether patients want opioids or don't want opioids. It's a matter of, how do we help manage their actual true condition of chronic pain? 

And empowering non-opioid options, investment and research into it, looking at the FDA for making sure that these type of modalities are things that are approved. And I know there's a certain number of drugs and other modalities that are non-opioids for managing pain that are out there, understanding the science around pain and putting some investment and research into it. Destigmatizing pain, because the problem with stigmatizing it is that it's sometimes kind of cast aside as something that we shouldn't even invest any resources in how to manage. 

So a big part of that—and as well as patients who have pain. They come and complain of being in pain. And after a while, they're looked at as being a problem patient, when in fact, they truly have issues. And they may go to other types of things like going into substance use disorders or other things, which kind of make them another target of being stigmatized when they actually do have underlying conditions that need to be managed. 

Some of them may need psychiatric treatment, which, again, there's a lot of payer issues when it comes to paying for psychiatric illnesses, as well as their chronic pain, as well as all their other issues. Making sure that we have that conversation, us as a medical board in the regulatory arena, making sure that we're informing our physicians, what are they going to be targeted for in managing and prescribing opioids versus, what are they not going to be targeted for as far as following the rules and making sure that they take care of patients appropriately? 

When I came on the Medical Board back in 2017 and the initial CDC guidelines talked about 90 MMEs as a guideline for the number of opioids that were being utilized, unfortunately, the medical board, before I came on, were actually sanctioning physicians for prescribing more than 90 MMEs, even though that's not what the guidelines said. The guidelines said that for those who are getting more than 90 MMEs, it is better for a primary care physician to consult with a specialist to help manage that pain. 

So we had to reverse a lot of that. We had to talk to state prosecutors and inform them that you don't go and just throw an indictment onto a physician for doing what they believed was correct. So that took a lot of education. 

That whole multi-faceted approach in managing a very serious epidemic that's out there is the only way that's going to solve it. Whittling it down to an easy—what looks like an easy solution of just punish and try to eliminate the availability of these things really kind of sweeps it under the rug. And again, as I said at the very beginning, forces these patients to go from the regulated environment into the unregulated environment. 

Which again, that's where we're seeing patient deaths. That's where we're seeing sentinel outcomes. And we've got to do everything we can to keep patients in that regulated environment. 

Dr. TerKonda: Dr. Suk—

Dr. Suk: Sure. Go ahead, Sarv, please. 

Dr. TerKonda: Building on what Dr. Zaafran was saying is one of the other things that we really have to consider is the disparities in access to pain care, especially among our marginalized populations. This involves education and making sure there's recommendations that call for equitable care across all—that consider the social determinants of health, ensuring that all patients have access to the appropriate pain management options, not just the opioids. 

Because we know that in the rural areas, it's easy to get illicit opioids. And we need to make sure that those marginalized populations still have the options of getting non-opioid therapy, I think building on this comprehensive approach of reducing this pain crisis that we have. 

Dr. Suk: Yeah. I appreciate that. And it spins on the question a little bit about access and perceptions, not only just from physicians' perspectives, but from patient perspectives. 

A narrowed question from the audience is looking at it from a patient perspective, what advice would you have to a patient when they can't access or afford non-opioid options that are recommended or are denied opioid therapy even though it's recommended? Do you have thoughts that attendees on this call can share with their patients on what to do? 

Dr. Zaafran: Well, as you alluded to earlier, the NOPAIN Act, looks like it's giving a directive to payers to actually pay for non-opioid modalities. So, I certainly hope that will create a shift in not only incentivizing, but mandating that payers actually pay for appropriate therapies. 

I will never forget the frustration I felt—I'm an anesthesiologist, and I work with surgeons to make sure that we have an appropriate way of making sure that patients, after they go home, are managed well. And when a patient comes back and tells me, you prescribed this multi-modality or this multi—number of medications that are out there, you prescribed the nonsteroidal anti-inflammatory, you prescribed this opioid, and you prescribed them these other medications, the opioid cost me $2 as a co-pay. This nonsteroidal anti-inflammatory cost me $200. Well, you know what? I'm just to have to give up on that nonsteroidal anti-inflammatory and just use this opioid that's over here. 

Or when you have opioids that are basically essentially combined drugs or combination drugs. So obviously, a lot of these medications are acetaminophen combined with either codeine or hydrocodone or oxycodone. When they're in the hospital, we try to maximize the use of acetaminophen and minimize the use of the opioids. 

But the way medications are dispensed out in the community, it's not easy to do it that way. And what are physicians going to do, and what are patients going to do? They're going to go to the least common denominator, which is what is easy. 

If you're managing 30, 40 patients a day, and you have to figure out a way to prescribe medications that are probably best practice, but practically speaking the way reimbursement works is actually incentivizing patients to do the wrong thing, then it doesn't matter what we say as far as putting guidelines out there. The practicality of the matter is that they're going to go where they can afford to go. So the NOPAIN Act, I hope that kind of pushes the conversation and direction where you're actually managing patients with best practice. 

But it's also a conversation with patients because what patients hear—and what was really important when we had our stakeholder meetings and we had chronic pain patients involved, what they hear is that we are going to limit their ability to access opioids. And in their mind, opioids are the only thing that at least have made them feel comfortable. 

So we've got to make sure that both physicians are having the right conversation with patients, that this is not about just taking away your opioids. It's about managing your process in a multi-disciplinary way so that we can figure out for you, what is the least amount of opioids that you can take while you are still becoming more and more functional? 

We've always heard this word about functionality being more important than potential for perceived pain. But that perceived pain and functionality goes back to, again, the nonmedical interventions for pain, which is the behavioral therapists and a lot of those other modalities like—again, things like music therapy and other types of therapy that can help patients. 

And how do we transition patients from chronic pain to acute plus chronic pain when they come for surgery and back into their chronic pain management? That seamless process going from primary care to surgical care and back to primary care. 

And from the surgical care standpoint, how do we make sure that we're managing these patients so that if they come in opioid-naive, that a year later all of a sudden they're still taking opioids? We know that about 10% to 12% of patients were opioid-naive who come and experience a surgical procedure, that a year later are still taking those opioids. What have we done as clinicians in helping not have patients go from being opioid-naive to all of a sudden having to take opioids on a chronic basis—what have we done to help minimize and mitigate against that? 

Dr. Suk: Yeah. Thank you for that additional comment. Referring to the NOPAIN Act, there was a specific question in the chat about whether acupuncture would be covered. And it's not specifically delineated in the act. However, the drive toward non-opioid alternatives, I think, may ultimately increase the window of opportunity for those who practice who want to prescribe acupuncture as one alternative. 

Going to the chat—or going to the Q&A, there's a question here that I'll read. What are effective ways to address unconscious bias in the provider community that continues to impact chronic pain care, especially among marginalized communities, specifically thinking of patient populations like sickle cell disease who are excluded from CDC opioid prescription guidelines until just recently? And I know all three of you dealt with this directly as you came up with the new recommendations, so I just open that up maybe to elaborate a little bit more when it comes to inequity. 

Dr. Zaafran: I've spoken a lot. I want to make sure that you guys get a chance. 

Dr. Suk: Hank, you want to take that for a bit? 

Dr. Chaudhry: Sure. I mean, it's a serious question. I think two things. One, our policy is focused on pain in general populations. It actually does not specifically address patients who have end-of-life care needs related to pain or sickle cell or other chronic conditions where it's almost a feature of their everyday living. Those are exceptions. Those individuals definitely need thoughtful care, and hopefully they're getting that from the specialists that take care of them. 

For the general population, I think the other message of our policy is that we don't have enough pain management specialists, as we all know, around the country. You will come across patients with pain, whether it's acute, subacute or chronic, and decisions need to be made thoughtfully. You need to be mindful of past histories that could lead to a situation where you have opioid use disorder, either unrecognized or worsened by what's done to manage that pain. 

So really, part of our policy is recognizing that there is a complexity here, but we want to make sure everyone gets compassionate, thoughtful care. Be aware that there are disparities. Be aware that we have implicit biases, all of us, sometimes in the management of patients. 

But we have an obligation through our Hippocratic, our Osteopathic oath to take care of patients as best we can and be open-minded. But be on the lookout for signs that may suggest that there's an issue with prolonged use or high-dose use of specifically opioids. I think those are among the messages that we're trying to get across, but this equity issue is a big one. 

Dr. TerKonda: Dr. Suk, I think the other issue we really need to touch upon is that this is pain management. And I think part of the comprehensive approach to this is to create an environment so that that patient can manage their pain, live with—we're not guaranteeing that they'll have no pain, but live in an environment where they can feel comfortable with the amount of pain they have to function in society. 

And that's why I think it's really important, educating the patients about the risk of opioids, no matter what disease process they may have underlying that's causing their pain. And again, part of that is a behavioral management, understanding that chronic pain will always be there. But we want to create an environment for yourself and provide the appropriate therapy so you can manage to perform your daily activities of life. 

And I think that's part of that educating the patients about the risk of opioid use, making sure that they have to understand overdose protection and they understand those strategies. We want to protect those patients and make sure they're getting the appropriate care. 

Dr. Chaudhry: Can I quickly mention one other thing, Dr. Suk? 

Dr. Suk: Yeah, Hank. 

Dr. Chaudhry: The other thing we're doing is realizing that we have limited resources. Though we care about this issue, one of the things the FSMB did, along with many other national organizations around the country, is to partner with the National Academy of Medicine, which I'm sure all you know has an action collaborative looking at the opioid epidemic, at least for the past five, six years. 

One of the things—and that's in—Admiral Levine, the Assistant Secretary of Health, is a part of that as a co-chair. 

One of the things we've learned is that there are some very good examples across the country in states and counties where there are some best practices emerging on how to manage the issues that you raised, Dr. Suk. And so sharing those best practices, which could become a regional or a national model is, I think, another way of looking at this. 

No one city, state or region has the solution or even at the federal level. But partnering together with clinicians who are actually dealing with this day in and day out is the way we get to understand this problem better and to do something about it. 

Dr. Zaafran: Yeah. You know, Michael, one of the things that the HHS task force did address specifically were these marginalized patients specifically. They did talk about sickle cell patients and other chronic patients—chronic pain patients that historically experienced chronic pain. 

And really, a big part of it—I saw in the chat earlier somebody talked about the education of medical students also and making sure that there is awareness, and that implicit bias is something that is taught. A lot of times when these patients do come to the emergency room, the implicit bias is that these guys are opioid seeking. 

Well, they may be, but that's actually kind of a tertiary response. They are in pain, and they are looking for comfort. And how we help manage that comfort really should be our first goal. It shouldn't be the first thought that these guys are opioid seeking and they're just trying to jump from one ER to another, and so forth and so on. They might be, but that's actually a secondary, a tertiary type of reaction to something that is underlying that they are experiencing. 

And as Dr. TerKonda alluded to a little bit earlier on, a lot of that does include behavioral therapy and other types of modalities to make sure that their perception and their functionality of the pain that they're experiencing, which is real, is also something that has to be managed. You can't just take away the opioids for their pain management without addressing the other side of that first. It has to go in conjunction. 

You can't just take one away and say, by the way, later on, whether you're able to access it or not, then we'll start helping you manage that part. Well, until they access it, they kind of need this other modality that's out there, and we've got to be very cognizant of that. 

What was said earlier on about not enough chronic pain physicians and access to care, and so forth, again, we've got to be able to leverage the telemedicine that is out there, the federal rules that allow for better reimbursement with telemedicine that kind of goes back to the days of COVID and making sure that there are opportunities to help continue that, especially around tele-prescribing with the appropriate guardrails. 

We at the Texas Medical Board refined our rules that were temporary during COVID around the prescribing of opioids. We still put a lot of guardrails around it with how often you need to see the patient physically, but allowing for some of those prescribing to happen in a telemedicine manner so that, again, your urban patient—or your rural patient doesn't have to travel 100 miles every 30 days or more frequently in order to access care that they truly may need. 

And again, kind of going back to my initial theme, making sure that we keep these patients in a regulated environment and not inadvertently forcing them into an unregulated environment by the way we are forced to help manage their pain, whether it's a payment issue, whether it's an access to care issue, whatever they might be. We as regulators, yes, we need to regulate how the care is being delivered, but we've also got to work with policymakers and others to make sure that we take down those barriers that allow them to get proper access to care. 

Dr. Suk: No, all very true, and very, very insightful. You mentioned the medical students in our education process that we have going on. This represents, I think, a new frontier of the things that we need to thoughtfully train students who are entering into the new workforce. These ideas of team-based care, multiple levels, multiple inputs and coordination, I think, is a little bit different than maybe, if I may say so freely, than when we trained, certainly. 

I wonder if you guys have any thoughts on the future of pain management education, how these particular regulations can actually impact that, because I do think there's going to be a significant influence. 

Dr. Chaudhry: I'm happy to start, Michael. I spent 10 years in undergraduate and graduate medical education. I know for a fact that many, many MD and DO schools are doing their best to incorporate exactly what you said in their curricula for not just the first and second-year students that are at the institution, but also prepare them for the third and fourth-year clerkships that they do, and ultimately residency. 

In fact, next month we have the CEOs of both the AAMC and AACOM appearing before our board at the FSMB so we can better understand, well, what's being taught to the next generation of physicians? It is our belief that they are getting a better training, if you will, than any of us did in both team-based care, understanding the role of the physician, understanding that patients may not always tell you what they need. 

And it takes some time, which is not always available. I'm hoping AI may play a role in allowing us to spend a little more time with patients rather than the technologies that hopefully can ambiently listen and take care of the documentation, because patients need to be listened to. That takes time. And they need the care to be tailored to their specific needs. 

And that's not always possible with specialists. There just aren't enough specialists available. So every doctor has to be aware and understand and work with nurses, pharmacists and others to provide the appropriate care. 

Dr. Suk: Yeah. 

Dr. Zaafran: Yeah, you know, one of the things that I think we're missing also is a fair amount of research going into helping manage this. There's a lot of genetic testing that can be done to allow us to help target our approach in pain management. There are certain medications that we know work better than others, opioids and non-opioids. 

I know we keep on talking about the payment issue, but if these things are not being paid for, then they're not going to be utilized, both in the psychiatric arena and in the substance use disorder arena. Helping leverage our technology and funding research, meaningful research in how we understand how patients perceive pain and how we can manage pain I think is going to be key in taking us to the next level and really properly managing it. 

And honestly, unless we destigmatize this whole thing, you're not going to get the kind of funding and research that I think is appropriate for what this warrants. Because unfortunately, things that are stigmatized don't necessarily get the kind of funding that it deserves. It may not be as sexy as cancer therapy and stuff like that. 

But again, remember, everything that's out there has a pain component to it. And unless we help manage that part in the whole process of co-morbid conditions and other disease processes, we're never going to really be able to help advance our understanding of how to manage this whole process. 

The only thing that we can do as regulators is work with what we have out there. As a physician, I can see where some of the problems lie and encourage more research, more funding, more education, all these kind of things, more collaboration, taking down some of those barriers. But we've got to be able to destigmatize what we say in the arena, in the public realm arena of who these patients are. 

They can't be marginalized. And if you marginalize them, it's almost like they don't exist. And if they don't exist, then you don't have to worry about treating them. That really can't continue to be the case. 

Dr. Suk: Yeah. Thanks. Sarv?

Dr. TerKonda: Yeah, I think in terms of the future of pain management, I think both Dr. Chaudhry and Dr. Zaafran alluded to some of these things, but incorporating genetic testing. There's going to be probably using AI to determine a model of care that's personalized for that patient. 

Why do I respond to oxycodone, but my patient does not? I mean, those are things that we need to identify biomarkers and therapeutic targets for each individual. I think we're going to have improved imaging in the future, looking at the pathways for pain to see how—what types of pathways, what type of brain activity they have, and why they may perceive the pain they do. 

Looking at other types of treatment, virtual reality. We're looking at how we can use virtual reality to basically distract that patient while we're doing a small procedure or a minor procedure. So I think there's going to be other alternative medical treatments. Acupuncture was mentioned, maybe some nutraceuticals, further non-narcotic methods. But I think we'll see a more expansion of those non-opioid, nonmedical, medication-based therapies in the future. 

Dr. Suk: Yeah. You know, going with that too, Sarv, technology was really kind of the next series of questions or a future that I was going to get into. You mentioned a couple that I think are important to reiterate and ensure that the audience here knows that down the pike—I mean, AI, genetic testing, our worlds are colliding with artificial or virtual reality, and things like that. 

What about the ones that exist today? What about the impact of things like telemedicine? Or how can we do more of—increase access via remote access versus in-person therapy? Do you see some future hope in that area? 

Dr. Zaafran: It all goes back to the barriers, right? We talked about the barriers earlier on from the payment side of things. Also, connectivity. If you don't have access to internet out in a rural area and you can't access telemedicine properly, that's another barrier. So payment, access. 

Making rules—and again, this kind of goes back to the state medical boards—to help empower physicians to collaborate with others to actually do the right thing. And that was kind of like the whole point of that goal plan that we were talking about. Incentivizing the use of telehealth, incentivizing the collaboration with those different disciplines out there to actually manage a patient in a proper manner. 

And the other thing, when Sarv actually talked about AI, predictive analytics. Who are—how can we better risk stratify patients who are going into a procedure as to who may actually be more at risk than somebody else? And helping make sure that we target those patients and properly address how we can maybe differently manage their pain, post-operatively and so forth? But again, the chronic pain patients that are out there, and making sure that they have that access that they need, which, again, goes back to payment, and so forth. 

Again, it all really goes back to how we as regulators and as physicians and clinicians can help take down those barriers to make sure that these patients have the access to the kind of care that they need, and that our regulators and legislators are not hindering the process, but maybe actually even promoting the process in a way that would be helpful to them. 

Dr. TerKonda: And Sherif, you bring up some great points, I think the other part of this is we need to look at prevention in the future. How can we use genetic testing to predict who would be highly—who has an addiction personality or an underlying addiction disorder? So then we can manage their treatment before they go into surgery or they have any other procedures going forward. 

Now, that's before the patient gets addicted. But I think we have to use these genetic testing models in the future, just like we know why some individuals don't respond to heparin and others do. We can use that information with the pharmacologic therapies that we use for pain control. 

Dr. Suk: Yeah. So I think that all of these things are really somewhat exciting, I think, in the future of what we can provide going forward when it comes to pain management. As we near the end of our time together, I want to just acknowledge the fact that I recognize there are a number of people on this webinar who they themselves are finding themselves in positions with acute and/or chronic pain conditions. And I'm glad that you were able to join to see the evolution of the regulatory environment, particularly as we move away from a very binary perspective on, what is opioid use and non-use, and only a limited set of ways to approach that. 

I think the future is incrementally going to get better, certainly with access and addressing inequities, and certainly some of the regulatory changes that are coming. And I hope that you walk away with a little sense of hope from this conversation today, that our Federation of State Medical Boards is working very, very hard to help make this happen. 

So I want to thank all of the audience, not only just for your questions, but also for our panelists for joining today, taking time out of their schedules to share with us this very important information. As you know, the AMA urges all state medical boards and legislators—state legislators to review their existing rules and use the updated 2024 FSMB guidelines. And doing so, it's our hope and our goal to help remove the stigma and harm that outdated, inappropriate rules and laws have caused. 

And so, what I would tell you, in addition, I want to thank you again for joining this webinar, which is one among many series, and just to give you a heads up of the next one that'll be coming up on October 18 on cybersecurity. All registrants here today will get an invitation to join us for that one coming up next month. 

But once again, Hank, Sherif, Sarv, well-esteemed doctors and real advocates in the world of pain management. I want to thank you for joining us on this AMA webinar and thank the audience once again for joining. Thanks, everybody. 

Dr. Chaudhry: Thanks, Michael.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.