July 2015

The USBJI responded to a request for comment on the Draft National Pain Strategy. As follows the input we submitted on May 20.

NINDS Office of Pain Policy     (NPSPublicComments@NIH.gov)
National Institutes of Health 
Department of Health and Human Services

Dear Colleagues,

In support of the Draft National Pain Strategy, we write on behalf of the United States Bone and Joint Initiative (USBJI), one of more than 60 National Action Networks which form part of the Global Alliance for Musculoskeletal Health, previously called the Bone and Joint Decade. Over one hundred professional, patient, and public organizations form our supporting network. The Initiative promotes awareness of the burden of musculoskeletal disorders, and efforts to reduce it, including increasing funding for relevant, high‐quality research. Our mission is to advocate and promote multidisciplinary, coordinated, and patient‐centered care, and thus improve the prevention, diagnosis, and treatment of musculoskeletal conditions. We recognize that over half of American adults report having a chronic musculoskeletal condition. These include low back pain, joint pain, and arthritis‐related disability (primarily osteoarthritis), each reported by 60 million or more Americans in 2012, as well as osteoporosis, broken bones including fragility fractures, children’s musculoskeletal conditions, muscle pain, and temporomandibular (TMJ) joint disorders. Annual direct and indirect costs of musculoskeletal conditions have risen to $874 billion (5.7% of the GDP). In spite of the economic and personal impact of these conditions, research funding has remained well below that of many other health problems. The USBJI and its network members recognize that chronic pain, as well as acute pain with potential to turn chronic, are common features of practically all the musculoskeletal conditions with which we are concerned. Improvements in the understanding, prevention, and care of chronic pain generally, as proposed by the Draft National Pain Strategy (NPS) will directly contribute to the needs of our patients. Effective deployment of the NPS will reduce the burden of these conditions that is shared, in various ways, by everyone in America.

With regard to the NPS’s objectives and action plans for the six areas of need identified in the 2011 Institute of Medicine report, we find many points with which to agree.

Population Research (p. 14) should improve our knowledge of overall prevalence, chronic pain subtypes, and variations among specific patient groups.  We need more precise differentiation between chronic pain and its presumed precursors. Longitudinal studies of sufficient statistical power will be helpful in this regard. Hopefully sufficient resources can be devoted to tracking individual patients to promote better definition of those at risk of developing chronic pain.

Prevention and Care (p. 20) are certainly opportunities for improvement. As discussed below, this area will be strengthened by actively and promptly including primary care physicians and other specialists – those who treat the conditions listed in appendix F (p. 60).  We would also urge you to increase emphasis for functional rehabilitation programs, and their synergistic contributions to pain relief.

Disparities. (p. 26) This area appropriately focuses on objective confirmation of the existence, prevalence, and severity of the recognized disparities, especially those involving minority groups and others who are disadvantaged socio‐economically. We would urge continued vigilance to identify presently unrecognized disparities, in addition to comparative research and efforts to provide equity in assessment and treatment.

Service Delivery and Reimbursement. (p. 30) Creation, and evidence‐based validation, of new models for collaborative multidisciplinary care may be impeded by reimbursement rules and policies such as “therapy caps”, which limit payments for both speech & language pathologists and physical therapists to a single capped total. Limited duration of therapeutic treatments may be insufficient for chronic pain patients. Investment in care innovations will require arrangements to permit both collaboration and studies of effectiveness before improved collaborative care models have an opportunity to reduce treatment costs included in the socio‐economic burden of chronic pain.

Professional Education and Training. (p.36) We notice that the NPS focuses appropriately upon the challenges of chronic pain. It appears to be the product of clinicians who are predominantly pain specialists and anesthesiologists, with supporting experts from research and administrative fields. However, the NPS seems to have been created largely without clinicians who are primary care providers or physician‐specialists in diagnosing and treating patients with the ailments typical of the diagnostic clusters listed in Appendix F (p. 60). Their absence may prove to be a barrier to elucidating the transitions from acutely painful conditions to established chronic pain syndromes. Under‐representation of such clinicians among those carrying out the NPS will certainly interfere with efforts to improve evidence‐based prevention and care. It will also pose difficulties for creating the called‐for culture change in understanding and addressing pain and its care, since the attitudes of those initially treating patients with pain will be crucial to making the desired changes. Finally, a broader range of participating clinicians would probably be more receptive to developing and accepting the curricular, certification, and licensure requirements that are proposed, essentially for all physicians (and selected non‐physicians as well). It would seem that these problems are not insurmountable, but surely they should be addressed by promptly including clinicians, both primary care providers and other specialists, who are active in the diagnosis, early treatment, and also definitive treatment of the conditions referenced by Appendix F. We would like to point out the effort currently underway by members of, and sponsored by, the USBJI to develop multidisciplinary care models for osteoarthritis, the Chronic Osteoarthritis Management Initiative (COAMI), as an indication of our commitment to the multidisciplinary care of osteoarthritis patients, using models similar to those designed for other chronic conditions. Clearly management of chronic arthritic pain must be an integral part of such efforts, and not a stand‐alone effort. Please see attached files (A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative , and Draft OA Model of Care: Core Components). The USBJI would happily be considered as another stakeholder (see p.38) regarding Objective 1 under Professional Education and Training.  

Public Education and Communication (p. 40) is another essential area for improvements in understanding and supporting the care of patients with chronic pain. Better understanding will drive the public side of culture change, and might increase acceptance and use of self‐management modalities.

Thank you very much for considering the overall support, and several suggestions submitted herewith by the United States Bone and Joint Initiative.

Sincerely,

Steve M. Gnatz, MD, MHA 
President, U.S. Bone and Joint Initiative 
Professor, Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center

David Pisetsky, M.D., Ph.D. 
President Elect, U.S. Bone and Joint Initiative Professor of Medicine (Rheumatology), Duke University
United States Bone and Joint Initiative

“Patient-reported outcomes to initiate a provider–patient dialog for the management of hip and knee osteoarthritis” a systematic review commissioned by the USBJI has been published (Seminars in Arthritis and Rheumatism, April 2015). Although many treatment guidelines exist for hip and knee osteoarthritis (OA), uptake in clinical practice is typically low. Valid patient-reported outcome measures (PROs) that can be easily used in the clinic could aid implementation and evaluation of treatment recommendations, and the tracking of symptoms and function over time. This project was undertaken in response to a 2012 Call to Action of the Chronic Osteoarthritis Management Initiative of the United States Bone and Joint Initiative; the authors aimed to develop a tiered list of recommended PROs that could be feasibly applied in common clinical settings, across four domains of pain, function, fatigue, and sleep.

PubMed: http://www.ncbi.nlm.nih.gov/pubmed/25979178
ScienceDirect: http://www.sciencedirect.com/science/article/pii/S0049017215000700.

The COAMI Steering Committee met in April to develop a plan for a new Model of Care for the Management of Osteoarthritis in the US. Three work groups are spearheading these plans, on Clinic Flow, Continuum of Care, and Shared Decision-Making Tools. The American College of Sports Medicine is spearheading another work group addressing aspects of physical activity. The Work Groups are recognizing the importance of incorporating social determinants into all components of the plan. The Development Plan can be seen here.

The OA Action Alliance Steering Committee met the day before the COAMI committee to develop a new strategic plan. COAMI is incorporated into the plan under the goal to Mobilize Health Systems and Health Care Professionals.