Today’s opioid crisis is “all about the synthetic opioids,” said Vanila Singh, MD, MACM, a pain medicine specialist and former UCLA faculty member, who now serves in Washington DC as Chief Medical Officer in the Office of the Assistant Secretary for Health at the Department of Health and Human Services (HHS).
Dr. Singh gave a riveting Grand Rounds presentation on June 19 to our department, titled “The Opioid Crisis: HHS Strategy and Advancing Pain Management.”
She explained that the rate of opioid-related deaths from prescription drugs started to rise in 1999, when the misguided “Pain is the 5th Vital Sign” campaign prodded doctors to prescribe opioids more liberally. However, Dr. Singh said, there is now a second wave of deaths from heroin use, four times worse today than in 2010. Today, powerful synthetic opioids like fentanyl are flooding into the US from China and other foreign suppliers, increasing the death rate from overdose.
“Cocaine and methamphetamine use are also on the rise,” Dr. Singh said. “We are in a full-blown drug crisis.”
She estimates that 50 million Americans endure chronic pain, and 19 million suffer from debilitating high-impact pain that imposes social isolation and impairs their function and quality of life.
As physicians cut back their opioid prescriptions on the advice of the 2016 CDC guidelines, many pain patients were left in the lurch, Dr. Singh said. Patients with chronic pain who were compliant with opioid use and weren’t “drug-seekers” were suddenly forced into rapid taper of their opioid medications, leading to severe pain and even to suicide. Others turned in desperation to the black market for heroin.
“The CDC guidelines have been misinterpreted,” Dr. Singh said, and turned into harsh state laws that may restrict opioid prescriptions to a week or less, even for severe postoperative pain. “A patient with a seven-level fusion may get only three days of opioids,” Dr. Singh said. “We need to put doctors in charge of medicine again.”
The HHS Pain Task Force
To tackle this difficult public health crisis, HHS established the Pain Management Best Practices Inter-Agency Task Force, which brought together experts in pain medicine, addiction, recovery, substance use disorders, mental health, minority health, and more. Chaired by Dr. Singh, the Task Force issued its final report in May, earning widespread praise from more than 150 organizations of physicians, nurses, pharmacists, psychologists, and patient advocates.
The report , accessible at hhs.gov, outlines five broad categories for pain treatment:
• Medication: opioid and non-opioid
• Restorative therapies: physical therapy, occupational therapy, exercise
• Interventional procedures
• Behavioral health approaches
• Complementary and integrative health measures such as yoga and Eastern medicine.
Both acute and chronic pain management should be “individualized, multimodal, and multidisciplinary,” Dr. Singh advised, and education at the curriculum level should lead to a “general, holistic understanding across specialties.”
The report’s recommendations include:
• Greater use of telehealth, tele-mentoring, and mobile apps
• Better third-party payment for non-opioid therapies, medication-assisted treatment, and behavioral health
• Educating primary care physicians and teams; encouraging appropriate referrals
• Improvements to coverage barriers
• Training of more pain medicine specialists to close workforce gaps.
“It’s high time to coordinate on this issue!” she said. Anesthesiologists need to be “part and parcel” of the battle. As opioid prescriptions have come under increasing scrutiny, physicians at the front lines have started refusing to treat chronic pain patients. Patients may be unfairly stigmatized as “addicts”, adding to the suffering they already endure from intractable pain.
“People talk about being dehumanized and treated like pariahs when they go to the ER or a clinic complaining of pain,” Dr. Singh said. Pointing out that June 19 is World Sickle Cell Day, she highlighted the fact that many patients in sickle cell crisis have severe pain but may be denied medication and viewed as “drug-seekers and second-class citizens.”
Dr. Singh emphasized that simple algorithms can’t adequately guide the practice of pain medicine. “There’s a need for individualized patient care,” she said. “Patients are not all the same and we don’t want to be treated that way. Even with similar diagnoses, patients will need different treatment plans due to co-morbidities and other factors.”
While she continues her work in HHS, Dr. Singh is on leave from her faculty position as a Clinical Associate Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University. She was a member of the UCLA faculty from 2002 to 2003, immediately after she completed residency and pain medicine fellowship training at Cornell-Weill University Medical Center in New York City. In 2016, Dr. Singh earned the Master’s degree in Academic Medicine (MACM) from Keck School of Medicine at the University of Southern California.
1. U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html