Episode 094: A Multimodal Approach to Pain Management

Speaker 1: You’re listening to Your Practice Made Perfect; support, protection, and advice for practicing medical professionals brought to you by SVMIC.

J. Baugh: Hello, everyone, and welcome to this episode of Your Practice Made Perfect. My name is J. Baugh. I'll be your host for today's podcast. Today, we're going to be talking about working on the HHS Pain Management Task Force. To help us discuss this very important topic is Dr. John McGraw. Dr. McGraw, welcome.

Dr. McGraw: Thank you, J., It's just wonderful to be with you guys today.

J. Baugh: Well, we're glad to have you here and we're looking forward to some discussion about a topic that is so important in medical practices these days. And before we get into the topic itself, maybe you could tell us a little bit about your background and how you came to be part of the task force.

Dr. McGraw: J., thank you. I actually am an old guy, have been out of practice seeing basic patients now for a few years, have switched into an administrative role as the medical director for OrthoTennessee. Long before I stopped actual day-to-day practice, I was quite worried about the overprescribing and the abuse of opioids, specifically, and other controlled substances in not just our practice but in society. I have 34 years of commissioned service in the Air Force and the Army. I saw firsthand how drug abuse in the military was started oftentimes with the overprescribing of various controlled substances to our soldiers, and sailors, airman.

Then, it became very apparent that we were in trouble back probably a dozen or more years ago when I kept seeing more and more of my patients not just demanding but actually naming the drugs that they wanted to have after a sprained ankle or something that normally should not require controlled substances for pain. Then, something happened five years ago, I was elected to County Commission in Jefferson County, which is a suburb of Knoxville. As the chairman of the finance committee, vice chairman of the budget committee, I started seeing that inordinate amount of our funds were going toward our law enforcement, our jails. Over 90% of the people that were incarcerated in our local county facility were there because of some sort of a drug problem and all the things that go around that.

So I became very acutely aware that not only were we having problems as medical professionals, but also society itself was suffering dramatically. Then, being on the hospital board, influx of patients who had been abusing substances that landed in the hospital in acute care situations due to chronic addictions that started oftentimes very simply by maybe a few too many opioids prescribed or because of diversion, where opioids or other controlled substances would be in a medicine cabinet and maybe someone else living in the house or somehow at a party, people would get these particular substances and misuse them. So this became a very round-the-world concern for me in lots of different topics, and that's why it was on my radar a long time ago.

J. Baugh: Yeah. My first question that I was planning to ask you had to do with when you became concerned about the opioid epidemic as we know it now, and it sounds like it's something that you've been tuned into for quite a long time, for several years now?

Dr. McGraw: It really has. I was chairman of the Board of Counselors for the American Academy of Orthopedic Surgeons in 2013 and '14. We had our fall meeting of the AAOS in Nashville back in September of 2014. I had some of our local experts on a panel, as well as a couple of national experts, and we approached the subject in this symposium, Opioids in The Practice of Orthopedic Surgery. The reason for it was that a crisis was looming. It didn't have as much publicity in those days, but I could see that it was looming and we needed to be at the front edge, the cutting edge, so to speak, of trying to solve this problem. Our symposium drew a lot of accolades nationally. It was already going, but it really added credence to the discussion that we as orthopedic surgeons needed to have on what our role was in stemming this problem and alleviating the crisis.

It was extremely well-received, and we as an American Academy of Orthopedic Surgeons started trying to do things like a pain management toolkit by which we as practicing physicians could understand the role of controlled substances, and the options, and alternatives to those in our pain management protocols. As you know, orthopedics only make up about 2.7% of all of the physicians in America yet because of our specialty and because of the fact that we deal with pain, acute pain primarily but also chronic pain in an everyday atmosphere, we use almost 6% of the opioids in America. So it became important for us to understand our role in pain management and to be able to provide a multimodal approach to pain instead of just simply taking out the prescription pad, jotting down a few more opioids, handing to a patient, and thinking that we've solved a problem when in some cases, we may have caused an even larger problem.

J. Baugh: Right. I can see where the opioid situation could be something that your specialty would need to be concerned with and take steps towards trying to ensure that this epidemic doesn't get any worse because there is a unique need for opioids when it comes to orthopedic medicine. So the task force that we're talking about is the HHS Pain Management Best Practices Task Force. So Dr. McGraw, how did you become nominated and eventually appointed to that task force?

Dr. McGraw: J., a very interesting process. I saw that President Obama had signed into law CARA, which stands for Comprehensive Addiction and Recovery Act of 2016, and I read some of the specifics in that act. By the way, it was a bipartisan piece of legislation that went through the house and the senate, and he very readily signed it. That particular piece of legislation gave a large amount of money to form this HHS Pain Management Best Practices Inter-Agency Task Force. Much had been made of the CDC guidelines that had been put out for opioid prescribing, primarily for chronic pain and for the primary care group of physicians and practitioners in America.

But this particular task force was to be made up of people with military backgrounds. That was a box that checked immediately for me. Those who had been elected to local regional offices. That was another thing for me. Those that were in high-use specialties, percentage-wise orthopedics was there. On and on, there were a number of things that I suddenly identified with. So I contacted, first of all, Congressman Phil Roe's office. Congressman Roe, of course, is a physician, retired OBGYN. He and I had had discussions about this long before it was very popular. He said, "John, you'd be an ideal person on the task force." I went then to Congressman Duncan's office, and he also knew about my work as medical director at OrthoTennessee. 

Both gentlemen wrote me very glowing nominating letters, and I sent these straight to Washington to our American Association of Orthopedic Surgeons, which is the political arm of our national organization, international organization. And then I went through what was called committee appointment process where people all over our 18,000-member organization were allowed to apply. I was nominated for this from both the AAOS as well as the two congressmen that represent Jefferson County where I was serving as, of course, county commissioner. So I intentionally sought it, and then I had, of course, a lot of help from friends to put me on this task force.

J. Baugh: So let's talk a little bit about the other members of the task force. What kind of specialties were the other members of the task force a part of? Was it representative of pain management experts from across the country?

Dr. McGraw: Very, definitely. And that was not just physicians. Interestingly, I was the only surgeon on the task force, per se. There was an oral surgeon, who was on the faculty of the dental school, who had done a lot of clinical research in demonstrating that you could get away with much of the oral surgery with far fewer opioids and with the use of things like acetaminophen, nonsteroidal anti-inflammatory agents. But there were many other physicians, including our chair, Dr. Vanila Singh, who was the chief medical officer at HHS and the Department of Human Health. Dr. Singh, by training and by her practice, had been an anesthesiologist with a fellowship in pain management. In fact, was chairing that department at Stanford when she was called by the administration to move to Washington and assume this important role at HHS, which included chairing this task force. So there were several of her specialty, emergency room physician, primary care physicians, and several involved in chronic pain management practices.

Also, besides physicians, we had several clinical psychologists that had done research in pain management and then we also had someone from the patient advocacy side. There are a number of groups around the country that advocate for patients who have chronic pain. And then also we had a representative from one of the veteran service organizations, which there are quite a few around the country, the American Legion and, of course, Veterans of Foreign Wars, and others that I've been a member of. So we had a representative, a retired army officer, on our task force in general with that. So it was a very broad spectrum of experts around the country who had done research, who had lectured, who had written about pain management. So I felt very honored to be in such an illustrious group of people.

J. Baugh: Well, that is good to know that the task force had so many different types of people. Like you said, a wide spectrum of interests were represented on that task force and that's good to know. Regarding the report that eventually went to Congress, could you give us just a few highlights of what was in that final report?

Dr. McGraw: Yes, be happy to do so. Let me just talk about the process just a little bit because this was not a fly by night, we all came in with our preconceived ideas and put them down on paper and that's it. This was a very hardworking task force. I put in hundreds of hours personally, and I know that each of the 29 members, 28 besides me, did the same thing. Some of them even more than me. We were subdivided in committees according to our expertise. We tackled various issues. So this report was extremely well-vetted not just within the task force itself but also the public and all of the agencies of the federal government, DEA, the CDC, and on and on, the CMS. All of these agencies were represented and had input into this particular report.

So we met in Washington three times. We put out a draft report on December the 30th of 2018. That draft report then was made public and by the way, all three of our meetings were televised nationally live around the country. So, I mean, there was no secrecy at all. This was done in public, and we did have selected people to come and testify in front of our organization, both from the patient community as well as the provider and as well as agencies. We, after December the 30th with putting out the draft report, then opened it to public comment for a 90-day period. We had over 6,000 public comments on the draft report. We summarized them, we read them, we looked at them carefully, and we revise that draft report based upon some of the public comments, not just from individuals but from major medical organizations. 

The Tennessee Pain Society put forth a beautiful letter complimenting us, but also stressing some of the importance in care of chronic pain patients. The American Academy of Orthopedic Surgeons, which I was represented, put forth two public comment letters. The AMA was very involved. All of the basic anesthesiologists and others gave us their input. And then on May 9th of 2019, we met in Washington for our final meeting, took into consideration all of the more than 6,000 comments, and put the draft report to a final report. We voted 28-1 to adopt this report, which is amazing in and of itself that we had had that good of leadership and then that we had had this much work to be able to come to evidence-based conclusions for the final report. And then that was actually filed in the report to Congress at the end of May of this year. 

Let me go over, J., and I apologize for that long discourse, but I think it's important to understand that this was not just a contrived report but this was the work of lots and lots of organizations as well as patients that testified in front of us. Let me go over two or three of the things that we think are very important in this report. First of all, that pain is not an isolated entity that can be approached as a modality. Pain is very complicated and therefore when we manage pain, both acute and chronic, it must be done in a multimodal approach. There are things besides just pills, or just an ice pack, or just acupuncture. All of these things come together as possibilities.

One of the biggest problems is that payers have balked at some of the more expensive things that evidence-based has proved to be effective. So the anesthesiology community knows this, that they can do blocks for instance. Little more expensive than a prescription for oxycodone or hydrocodone, but in some cases, more effective. Some of the nonsteroidals and other prescription drugs can be used in place of the dangerous opioids. So multimodal approach, lots of different options, and each patient has to be individualized with either himself or herself and that provider, that physician, who is approaching the pain.

Second of all, we need more education. There is no doubt that we have been prescribing in a vacuum somewhat. Of course, in Tennessee, we have the two hours required CME. I think that's inadequate. Personally, I think we need more than that, and we have strongly encouraged all the medical schools and dental schools as well as advanced practice provider schools such as nurse practitioners and PAs to have increased education in pain awareness and pain management. 

Finally, I would say that we have not treated patients as we should in regards to them being a biopsychosocial individual. We know that there are huge placebo effects. If I walk into a patient's office and I am caring, and compassionate, and engaged, and we have shared decision-making in the process, I know that I can accomplish more than just, "Dr., my pain is just unbearable." "Okay, well here. Take some of these pills, and let's see if we can help you with that." We need to engage our patients because there are all sorts of things that really come into the pain management aspect of our practice.

I have a friend in Texas who has shown that if, before he schedules a total knee or total hip replacement, he has that patient meet with a behavioral health expert that in as many as 30% of the cases they can detect major depression, major social problems, things that would block a successful total joint replacement. And if those things can be addressed ahead of time, then that surgical procedure will end up being successful more times than not. 

I was always amazed throughout my career as a total joint replacement surgeon that I would do the exact same total knee replacement on two patients. One would have stellar results and just be singing my praises and be productive to society, and the other person wouldn't do as well and they would have problems. Well, it's because I think I personally did not perceive some of the needs of my patients other than the fact that their X-ray showed bone on bone in their knee. So the report emphasizes the biopsychosocial nature of pain, and that we have to approach this as caring practitioners in trying to help that patient through the acute pain stage and then if there is chronic pain. We need to be more perceptive as providers and practitioners in the pain arena and because we need more education, we hope that that will help in our understanding of how we approach pain.

J. Baugh: Well, Dr. McGraw, it sounds like we've really just scratched the surface when it comes to addressing a problem that's as complex as opioid use is. I want to ask you a question that I think I already know the answer to, but I'd like to ask it anyway and that is do you feel that your service on the task force was worthwhile?

Dr. McGraw: That's a good question, and I actually wrote a small piece in this past month's AAOS Now, our professional trade magazine, about my service You know, I raised my hand on four different occasions to serve my country, both the Air Force, the Army, as a county commissioner, and then raised by hand to be a special government employee on this task force, and the answer is overwhelmingly yes. I cannot begin to tell you how rewarding it was to be able to put forth the document to Congress that hopefully will help not just our Tennessee delegation, but all of our 435 members of the house and 100 members of the senate as they approach legislation that hopefully can give us some relief from the opioid epidemic in our country. It was not only a wonderful thing from a patriotic standpoint, but I thoroughly enjoyed getting to know the other members of our task force who equally had a passion for doing the right thing when it came to our patients and the citizens of our country.

J. Baugh: Well, Dr. McGraw, we want to end by, first of all, thanking you for your service to our country in the military and also for your service to our country by serving on this task force. And thank you for sharing your thoughts with us today.

Dr. McGraw: Thank you very much.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, J. Baugh. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast.

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