Pain Management for
People with Serious Illness
in the Context of the
Opioid Use Disorder Epidemic
PROCEEDINGS OF A WORKSHOP
Laurene Graig, India Olchefske, and Joe Alper, Rapporteurs
Roundtable on Quality Care for People with Serious Illness
Board on Health Care Services
Board on Health Sciences Policy
Health and Medicine Division
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This activity was supported by Aetna Inc., Altarum Institute, American Academy of Hospice and Palliative Medicine, American Cancer Society, American Geriatrics Society, Anthem Inc., Ascension Health, Association of Professional Chaplains, Association of Rehabilitation Nurses, Blue Cross Blue Shield Association, Blue Cross Blue Shield of Massachusetts, Blue Cross and Blue Shield of North Carolina, Bristol-Myers Squibb, The California State University Institute for Palliative Care, Cambia Health Solutions, Cedars-Sinai Health System, Center to Advance Palliative Care, Centers for Medicare & Medicaid Services, Coalition to Transform Advanced Care, Excellus BlueCross BlueShield, Federation of American Hospitals, The Greenwall Foundation, The John A. Hartford Foundation, Hospice and Palliative Nurses Association, Kaiser Permanente, Susan G. Komen, Gordon and Betty Moore Foundation, National Coalition for Hospice and Palliative Care, National Hospice and Palliative Care Organization, National Palliative Care Research Center, National Patient Advocate Foundation, National Quality Forum, The New York Academy of Medicine, Oncology Nursing Society, Patient-Centered Outcomes Research Institute, Social Work Hospice and Palliative Care Network, Supportive Care Coalition, and the National Academy of Medicine. The MAYDAY Fund also provided support for this project. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-49223-2
International Standard Book Number-10: 0-309-49223-8
Digital Object Identifier: https://doi.org/10.17226/25435
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Copyright 2019 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Pain management for people with serious illness in the context of the opioid use disorder epidemic: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25435.
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PLANNING COMMITTEE FOR A WORKSHOP ON PAIN MANAGEMENT FOR PEOPLE WITH SERIOUS ILLNESS IN THE CONTEXT OF THE OPIOID USE DISORDER EPIDEMIC1
ANDREW DREYFUS (Co-Chair), President and Chief Executive Officer, Blue Cross Blue Shield of Massachusetts
JAMES A. TULSKY (Co-Chair), Chair, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Chief, Division of Palliative Medicine, Brigham and Women’s Hospital; Professor of Medicine and Co-Director, Center for Palliative Care, Harvard Medical School
PATRICIA A. BOMBA, Vice President and Medical Director, Geriatrics, Excellus BlueCross BlueShield
STEVE CLAUSER, Director, Healthcare Delivery and Disparities Research Program, Patient-Centered Outcomes Research Institute
REBECCA A. KIRCH, Executive Vice President of Healthcare Quality and Value, National Patient Advocate Foundation
JANE LIEBSCHUTZ, Chief, Division of General Internal Medicine, University of Pittsburgh Medical Center Health System, University of Pittsburgh School of Medicine
SALIMAH MEGHANI, Associate Professor of Nursing and Term Chair in Palliative Care, Department of Biobehavioral Health Sciences; Chair, Graduate Group in Nursing; Associate Director, NewCourtland Center for Transitions and Health; Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania
R. SEAN MORRISON, Director, National Palliative Care Research Center
JUDITH PAICE, Director, Cancer Pain Program, Division of Hematology-Oncology, and Research Professor of Medicine, Feinberg School of Medicine, Northwestern University
PHILIP A. PIZZO, Founding Director, Stanford Distinguished Careers Institute; Former Dean and David and Susan Heckerman Professor of Pediatrics and of Microbiology and Immunology, Stanford University School of Medicine
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
CHRISTIAN SINCLAIR, Outpatient Palliative Oncology Lead, Division of Palliative Medicine, University of Kansas Medical Center, representing the American Academy of Hospice and Palliative Medicine
Project Staff
LAURENE GRAIG, Director, Roundtable on Quality Care for People with Serious Illness
SYLARA MARIE CRUZ, Research Associate
RAJBIR KAUR, Senior Program Assistant
SHARYL NASS, Director, Board on Health Care Services, and Director, National Cancer Policy Forum
INDIA OLCHEFSKE, Research Associate (until June 2019)
ANDREW M. POPE, Director, Board on Health Sciences Policy
Consultant
JOE ALPER, Consulting Writer
ROUNDTABLE ON QUALITY CARE FOR PEOPLE WITH SERIOUS ILLNESS1
LEONARD D. SCHAEFFER (Chair), Judge Robert Maclay Widney Chair and Professor, University of Southern California
JAMES A. TULSKY (Vice Chair), Chair, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Chief, Division of Palliative Medicine, Brigham and Women’s Hospital; Professor of Medicine and Co-Director, Center for Palliative Care, Harvard Medical School
JENNIFER BALLENTINE, Executive Director, The California State University Institute for Palliative Care
ROBERT A. BERGAMINI, Medical Director, Palliative Care Services, Mercy Clinic Children’s Cancer and Hematology, representing the Supportive Care Coalition
AMY J. BERMAN, Senior Program Officer, The John A. Hartford Foundation
LORI BISHOP, Vice President of Palliative and Advanced Care, National Hospice and Palliative Care Organization
PATRICIA A. BOMBA, Vice President and Medical Director, Geriatrics, Excellus BlueCross BlueShield
SUSAN BROWN, Senior Director, Health Education, Susan G. Komen
GRACE B. CAMPBELL, Assistant Professor, Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, representing the Association of Rehabilitation Nurses
STEVE CLAUSER, Director, Healthcare Delivery and Disparities Research Program, Patient-Centered Outcomes Research Institute
PATRICK CONWAY, President and Chief Executive Officer-Elect, Blue Cross and Blue Shield of North Carolina
DAVID J. DEBONO, Medical Director, Oncology, Anthem Inc.
CHRISTOPHER M. DEZII, Lead, Quality and Measure Development, State and Federal Payment Agencies, U.S. Value, Access and Payment, Bristol-Myers Squibb
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
ANDREW DREYFUS, President and Chief Executive Officer, Blue Cross Blue Shield of Massachusetts
CAROLE REDDING FLAMM, Executive Medical Director, Blue Cross Blue Shield Association
MARK B. GANZ, President and Chief Executive Officer, Cambia Health Solutions
ZIAD R. HAYDAR, Senior Vice President and Chief Clinical Officer, Ascension Health
PAMELA S. HINDS, Director of Nursing Research and Quality Outcomes, Children’s National Health System
HAIDEN HUSKAMP, 30th Anniversary Professor of Health Care Policy, Harvard Medical School
KIMBERLY JOHNSON, Associate Professor of Medicine, Senior Fellow in the Center for the Study of Aging and Human Development, Duke University School of Medicine
CHARLES N. KAHN III, President and Chief Executive Officer, Federation of American Hospitals
REBECCA A. KIRCH, Executive Vice President of Healthcare Quality and Value, National Patient Advocate Foundation
TOM KOUTSOUMPAS, Co-Founder, Coalition to Transform Advanced Care
SHARI M. LING, Deputy Chief Medical Officer, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services
BERNARD LO, President and Chief Executive Officer, The Greenwall Foundation
JOANNE LYNN, Director, Center for Elder Care and Advanced Illness, Altarum Institute
DIANE E. MEIER, Director, Center to Advance Palliative Care
AMY MELNICK, Executive Director, National Coalition for Hospice and Palliative Care
JERI L. MILLER, Chief, Office of End-of-Life and Palliative Care Research, and Senior Policy Analyst, Division of Extramural Science Programs, National Institute of Nursing Research, National Institutes of Health
R. SEAN MORRISON, Director, National Palliative Care Research Center
BRENDA NEVIDJON, Chief Executive Officer, Oncology Nursing Society
HAROLD L. PAZ, Executive Vice President and Chief Medical Officer, Aetna Inc.
JUDITH R. PERES, Long Term and Palliative Care Consultant, Clinical Social Worker and Board Member, Social Work Hospice and Palliative Care Network
PHILLIP A. PIZZO, Founding Director, Stanford Distinguished Careers Institute, Former Dean and David and Susan Heckerman Professor of Pediatrics and of Microbiology and Immunology, Stanford University School of Medicine
THOMAS M. PRISELAC, President and Chief Executive Officer, Cedars-Sinai Health System
JOANNE REIFSNYDER, Executive Vice President, Clinical Operations and Chief Nursing Officer, Genesis Healthcare, representing the Hospice and Palliative Nurses Association
RACHEL ROILAND, Director, Serious Illness Care Initiative, National Quality Forum
JUDITH A. SALERNO, President, The New York Academy of Medicine
DIANE SCHWEITZER, Acting Chief Program Officer, Patient Care Program, Gordon and Betty Moore Foundation
KATRINA M. SCOTT, Oncology Chaplain, Massachusetts General Hospital, representing the Association of Professional Chaplains
KATHERINE SHARPE, Senior Vice President, Patient and Caregiver Support, American Cancer Society
JOSEPH W. SHEGA, Regional Medical Director, VITAS Hospice Care, representing the American Geriatrics Society
CHRISTIAN SINCLAIR, Outpatient Palliative Oncology Lead, Division of Palliative Medicine, University of Kansas Medical Center, representing the American Academy of Hospice and Palliative Medicine
SUSAN ELIZABETH WANG, Regional Lead for Shared Decision-Making and Advance Care Planning, Southern California Permanente Medical Group, Kaiser Permanente
Roundtable on Quality Care for People with Serious Illness Staff
LAURENE GRAIG, Director, Roundtable on Quality Care for People with Serious Illness
SYLARA MARIE CRUZ, Research Associate
RAJBIR KAUR, Senior Program Assistant
INDIA OLCHEFSKE, Research Associate (until June 2019)
MICAH WINOGRAD, Financial Officer
SHARYL NASS, Director, Board on Health Care Services, and Director, National Cancer Policy Forum
ANDREW M. POPE, Director, Board on Health Sciences Policy
Reviewers
This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
HAILEY W. BULLS, Moffitt Cancer Center
JESSICA MERLIN, University of Pittsburgh
BOB TWILLMAN, University of Kansas School of Medicine
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by SARA ROSENBAUM, The George Washington University. She was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.
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Acknowledgments
The National Academies of Sciences, Engineering, and Medicine’s Roundtable on Quality Care for People with Serious Illness wishes to express its sincere gratitude to the Planning Committee Co-Chairs, Andrew Dreyfus and James Tulsky, for their valuable contributions to the development and orchestration of this workshop. The roundtable also wishes to thank all of the members of the planning committee, who collaborated to ensure a workshop complete with informative presentations and rich discussions. Finally, the roundtable thanks the speakers and moderators, who generously shared their expertise and their time with workshop participants.
Support from the many annual sponsors of the Roundtable on Quality Care for People with Serious Illness is critical to the roundtable’s work. The sponsors include Aetna Inc., Altarum Institute, American Academy of Hospice and Palliative Medicine, American Cancer Society, American Geriatrics Society, Anthem Inc., Ascension Health, Association of Professional Chaplains, Association of Rehabilitation Nurses, Blue Cross Blue Shield Association, Blue Cross Blue Shield of Massachusetts, Blue Cross and Blue Shield of North Carolina, Bristol-Myers Squibb, The California State University Institute for Palliative Care, Cambia Health Solutions, Cedars-Sinai Health System, Center to Advance Palliative Care, Centers for Medicare & Medicaid Services, Coalition to Transform Advanced Care, Excellus BlueCross BlueShield, Federation of American Hospitals, The Greenwall Foundation, The John A. Hartford Foundation,
Hospice and Palliative Nurses Association, Kaiser Permanente, Susan G. Komen, Gordon and Betty Moore Foundation, National Coalition for Hospice and Palliative Care, National Hospice and Palliative Care Organization, National Palliative Care Research Center, National Patient Advocate Foundation, National Quality Forum, The New York Academy of Medicine, Oncology Nursing Society, Patient-Centered Outcomes Research Institute, Social Work Hospice and Palliative Care Network, Supportive Care Coalition, and the National Academy of Medicine. The roundtable is grateful to the MAYDAY Fund for its generous support for this workshop.
Contents
UNDERSTANDING THE OPIOID USE DISORDER EPIDEMIC AND ITS IMPACT ON PATIENTS, FAMILIES, AND COMMUNITIES
A Patient’s Perspective on Opioid Use in Serious Illness
Opioid Correction Versus Opioid Trauma: Where Policy Meets Chronic Pain
Disparities in Access to Pain Medications
ADDRESSING THE CHALLENGE OF PATIENTS WITH COMORBID SUBSTANCE USE DISORDER AND SERIOUS ILLNESS
Acronyms and Abbreviations
AMA | American Medical Association |
CBD | cannabidiol |
CDC | Centers for Disease Control and Prevention |
CMS | Centers for Medicare & Medicaid Services |
DEA | Drug Enforcement Administration |
DSM-V | Diagnostic and Statistical Manual of Mental Disorders, 5th Edition |
FDA | Food and Drug Administration |
HHS | U.S. Department of Health and Human Services |
IOM | Institute of Medicine |
MAT | medication-assisted treatment |
NGA | National Governors Association |
NIH | National Institutes of Health |
NOWS | neonatal withdrawal syndrome |
OPR | opioid pain reliever |
PDMP | prescription drug monitoring program |
PQ-MSAS | PediQUEST Memorial Symptom Assessment Scale |
SAMHSA | Substance Abuse and Mental Health Services Administration |
STORM | Stratification Tool for Opioid Risk Management |
VA | U.S. Department of Veterans Affairs |