by Amy Goldstein, MSW, Director, AACIPM
What is CARA and how does it relate to the work of AACIPM and whole health pain management?
Let’s connect some dots to help our AACIPM readers understand how the federal policy called “CARA” is connected to our work, and to underscore the alignment among the many different stakeholders related to individualized, multidisciplinary pain care.
We know that governmental policy (state or federal law, rule, regulation, agency decision, or guideline) has a significant impact on the practice of healthcare and people living with pain. CARA is one of those policies. In recent years, many hundreds of policies have been enacted to address opioid misuse and pain management, the majority of which have happened on the state level. Among the federal laws, the Comprehensive Addiction and Recovery Act (P.L. 114-198), known as CARA, was first enacted in July 2016.
CARA was considered landmark legislation and had unprecedented bipartisan support. Hard work, including many changes and compromises, took place before it landed on President Obama’s desk for his signature. The final version included 50 sections of detailed provisions. It was a clear and deliberate attempt to be a coordinated and comprehensive response to the nation’s opioid overdose and misuse epidemic.
Two components of CARA that are important to this Alliance include:
- Establishment of the HHS Interagency Pain Management Best Practices Task Force:
Section 101 “established an interagency task force, led by the Department of Health and Human Services, to develop a set of best practices for chronic and acute pain management and prescribing pain medication”.
Dr. Vanila Singh served as Chair of the Inter-Agency Pain Management Task Force established by the CARA Act of 2016. Through her visionary leadership and dedication, Dr. Singh was able to galvanize the task force members and promote unprecedented stakeholder engagement seen through thousands of incoming public letters plus endorsement of the final report by nearly 200 organizations. The seminal report was released in May 2019 and continues to be used and referenced daily. This report presents a roadmap for person-centered, multidisciplinary pain management that is a resource across the country.
- Issuance of the directive for the Veteran Administration’s Whole Health Initiative pilot:
Section 933 “established a pilot program within HHS to determine the feasibility of whether complementary and integrative health programs could add to the existing system of pain management and other health care services for Veterans”.
This mandate led to the ultimate and radical redesign of healthcare at the VA with creation of the Whole Health Initiative pilot in 18 geographically defined sites.
“What Matters to You, not What is the Matter with You”
At its core, this phrase really connects key stakeholders to the practical implementation of the biopsychosocial + spiritual approach to pain management and self-care. The VA’s website states, “Whole Health is VA’s cutting-edge approach to care that supports your health and well-being. Whole Health centers around what matters to you, not what is the matter with you”.
This important phrase has also been used and promoted across other patient-engagement efforts, such as during the May 2020 symposium by the Alliance to Advance Comprehensive Pain Management, Innovation & Progress in Person-Centered Pain Management. On day two, citizen leaders from PAIN-KC, a program of the Center for Practical Bioethics, with a staff person from the American Academy of Family Physicians, facilitated the session: Patient Engagement: Changing the Conversation Moving from What’s the Matter With You to What Matters to You? You can find video and slides of this presentation here.
Advanced by Passage of CARA, Veterans Connected to Whole Health Increased by 193%
In April 2021, the Veterans Administration released initial findings from this pilot showing an increase in Whole Health services to Veterans by 193%.
The Veterans Administration radically changed its approach to health care and is piloting the Whole Health Initiative in 18 sites. The Whole Health approach to care features conventional clinical care (such as pharmacy, medical care, or counseling) and complementary and integrative care (such as acupuncture or yoga) working together as part of an overall treatment plan.
Veterans who used Whole Health services to manage their chronic pain used opioid medications three times less compared to those who did not, and the pain outcome measures improved.
Veterans who used Whole Health services reported being able to manage stress better and noted the care they received as being more patient centered. These results indicate improvements in Veterans’ overall well-being.
The Institute of Medicine (now NAM) as a Catalyst for Future Changes
Past activities leading to:
- Whole Health Initiative Pilot
- The National Pain Strategy
- HHS Interagency Task Force
Advocates know that it takes considerable effort—and engagement from dedicated stakeholders—to move from an idea to an enforceable policy. I personally enjoy the organic nature of how “issue-spotting” and “opportunity-identification” often begins, and that it can be any discussion or meeting or activity that might be the catalyst for future change. Here are examples of this effort in process over many years and by many stakeholder organizations. It is collaborative and consistent efforts like these that move discussions and decisions to produce a favorable result.
In early 2009, the Institute of Medicine (IOM) convened the Summit on Integrative Medicine and the Health of the Public in Washington, DC. Dr. Donald Berwick’s memorable keynote address was around the patient-centered focus of “what matters to you”. Dr. Tracy Gaudet and many others in attendance were in strong agreement with this philosophy and the need for whole person aligned care. It would be ten years later when the VA rolled out its Whole Health Initiative pilot in 18 sites, under Dr. Gaudet’s visionary leadership as past Director of the Office of Patient Centered Care and Cultural Transformation. Commitment over the long-term is required to see the hard work of advocacy pay off in significant changes.
In 2011, the Institute of Medicine issued Relieving Pain in America, a report that estimated 100 million people live with chronic pain, costing approximately $640 billion annually in medical expenses and lost productivity, yet the disease remains widely undertreated. A core recommendation of this report called for a National Strategy—”The Secretary of the Department of Health and Human Services should develop a comprehensive, population health-level strategy for pain prevention, treatment, management, education, reimbursement, and research that includes specific goals, actions, time frames, and resources.” “The seminal report was a catalyst for future action and unprecedented levels of collaboration among multi-stakeholder organizations, including within U.S. Health and Human Services.
In the coming years, multiple initiatives ramped up, including the Center for Practical Bioethics’ PAINS Project, to galvanize around implementing a coordinated strategy across the country. These efforts kept at the forefront the high prevalence and societal costs of chronic pain, illuminating the stigmatization and marginalization of people living with this disease. It also underscored that the burden of pain is not equal across communities. Pain assessment, screening, and treatment varies by race and ethnicity, education attainment, income level, age, and gender. As a result, pain is undertreated and poorly managed for many underserved communities.
In March 2016, after long-time stakeholder engagement, including at a coordinated federal level, the National Pain Strategy, A Comprehensive Population Health-Level Strategy for Pain, was released. This strategy included short, medium and long-term recommendations across six areas, Population research, Prevention and care, Disparities, Service delivery and payment, Professional education and training, & Public education and communication. There were high hopes by many that this strategy would get funds appropriated by Congress for implementation. That never happened but fortunately, pieces of the strategy are still being worked on through relevant other efforts, such as the Alliance to Advance Comprehensive Integrative Pain Management, because some are practical recommendations.
NAM Workshop About Role of Nonpharmacological Approaches in December 2018
Considering the current evidence base, authors of current guidelines and systematic reviews/meta-analysis opine about the quality of evidence to definitively confirm which pain management strategies are optimal for which patients and which are likely to produce consistently reproducible and sustainable results for which patients. However, during a workshop hosted by the National Academies of Medicine in December 2018, the Role of Nonpharmacological Approaches to Pain Management, leading experts reviewed the current state of evidence on the effectiveness of nonpharmacological treatments and integrative health models for pain management, as well as policies related to coverage. There was agreement from many in attendance that there is ample evidence to act now and increase access to evidence-informed nonpharmacological approaches to pain management. These limitations, or differences in interpretation within the evidence, lead different policy makers to come to diverse conclusions about what should and should not be clinically supported or covered within insurance reimbursement policies.
Comprehensive Addiction and Recovery Act—CARA, CARA 2.0, CARA 3.0
Later that year, in July 2016, the Comprehensive Addiction and Recovery Act was signed into law. As mentioned earlier in this blogpost, Section 101 of CARA established an interagency pain management task force, led by the Department of Health and Human Services, to develop a set of best practices for chronic and acute pain management. That work began in 2017 and came to fruition in record time with the release of the Task Force report in May 2019. There is currently strong alignment among numerous leaders and organizations to continue to advance this roadmap for pain management.
Within that timeframe, the second iteration of CARA, or CARA 2.0, was enacted in 2018 to increase the funding authorization levels. The policy changes in this version were generally about prescribing or dispending opioids and treatments for substance use disorder.
Key Measures and Timing of CARA 3.0
In March 2021, the third iteration of the Comprehensive Addiction and Recovery Act, or CARA 3.0, (S. 987), was introduced in a bipartisan effort by U.S. Senators Rob Portman (R‐Ohio), Sheldon Whitehouse (D‐R.I.), Shelley Moore Capito (R‐W.Va.), Amy Klobuchar (D‐Minn.) and Jeanne Shaheen (D‐N.H.) to increase the funding authorization levels for the CARA programs enacted in 2016.
CARA 3.0 is a comprehensive approach to tackling issues related to substance use disorders but it also addresses aspects of chronic and acute pain management. Of note, among its key measures are provisions directing additional research into non-opioid pain management treatment, increasing continuing education for physicians for pain management and addiction, and incorporating changes in grant programs data collection to achieve more equitable outcomes. CARA 3.0 (as compared to the CARA 2.0 version introduced in the last Congress that included strict federal limits on all initial opioid prescriptions of three days) does not contain restrictions on opioid prescribing. Advocacy efforts led by National Pain Advocacy Center addressed the disparities related to this language which resulted in changes to this version. Instead, CARA 3.0 focuses on expanding other options for treating pain and contains language from the NOPAIN Act requiring the U.S. Department of Health and Human Services to report to Congress on identified gaps in Medicare coverage for pain and to make recommendations to increase patient access to these therapies.
What is the Timing for CARA 3.0? We should begin to see oversight and implementation hearings this fall 2021. There will be focused efforts to improve management language and provisions on pain and pain management in this bill so that it is a more comprehensive approach to substance use disorder and pain management and avoids perpetuatin stigma. We might see a final mega-bill rolled out in spring 2022.
What Can We Do Next
These laudable efforts have addressed the stigmatization of people living with substance use disorder with a comprehensive model of prevention, education, treatment and recovery, rather than law enforcement alone. The stigmatization and marginalization of people living with chronic pain (and mental health challenges) has been evidenced for decades and I challenge us to use CARA 3.0, or other levers, to speak out boldly. We have so much foundational work to educate and motivate decision-makers to take actions that are practical, pragmatic and definitive in addressing the needs of people with pain and the health care systems that support them.
Planned data collection in CARA 3.0 that addresses equitable outcomes in pain management and substance use is very important. This is an opportunity to leverage efforts and resources towards understanding more about pain (data about substance use disorder already exists from CDC) and building the needed pipeline of providers who can address the demand for comprehensive pain management and substance use disorder treatment in underserved settings.
Furthermore, the plans to increase education in pain management and addiction for physicians is important, and requires a comprehensive approach that is truly integrative and interprofessional.
AACIPM encourages stakeholders to continue the tireless efforts toward our common goals. The CARA 3.0 efforts currently underway, will bring to light the ongoing need to address pain management and provides yet another real-time opportunity to open dialogue and policy development efforts that align with the historical work and strategic vision of our collaborative efforts. AACIPM is proud to be a part of this team effort.