The Joint Commission, the powerful accreditor of hospitals and delivery organizations in the U.S., is making some significant changes to pain requirements, according to the agency’s New and Revised Standards Related to Pain Assessment and Management published in its July 2017 newsletter.
In 2014, the police-force in medical delivery revised its pain standard and elevated the value of acupuncture, chiropractic, mind-body, and other non-pharmacologic approaches. Yet the action, transformative as it appeared to be, lacked a mandate. Hospitals were not held accountable based on compliance with the new standard. They could fail to comply with the revision without risk to their accredited status.
For advocates of using less invasive, non-pharmacologic approaches first for pain, the Joint Commission’s announcement was exciting, yet rang hollow. The prize hadn’t quite been delivered. However, now the Joint Commission has remedied the omission in its newly revised standards, the first charge to leadership on pain management being, ” “The hospital provides nonpharmacologic pain treatment modalities.”
The use of integrative therapies and practitioners with minimal adverse-effects got a further plug in the first standard under the provision of pain services. Leaders are to “minimize[s] the risks associated with treatment,” a guideline that could be seen as a nod to opioid addiction and the ravages that is causing across the U.S.
The Joint Commission’s actions on the 2015 standard, and on the present assessment and management requirements, have each been provoked by activism from the integrative health community. Chief among them are acupuncturist researcher Arya Nielsen, PhD, and Marsha Handel, MLS, and the Academic Consortium for Integrative Medicine and Health (ACIMH). The ACIMH and the Integrative Health Policy Consortium (IHPC) were among those who promoted a February letter-writing campaign after the Joint Commission’s draft was released.
The powerful symbolic meaning of the Joint Commission’s new scoring requirement comes in the third standard in the same section. “The hospital either treats the patient’s pain or refers the patient for treatment. Note: Treatment strategies for pain may include pharmacologic and nonpharmacologic nonpharmacologic and pharmacologic, or a combination of approaches.” The therapeutic order for pain management is reversed.
Notably, the Joint Commission chose not to specifically reference any non-pharmacologic approaches. This is in contradistinction to the draft, which included, “The hospital promotes access to nonpharmacologic pain treatment modalities (this may include alternative modalities, such as, chiropractic, relaxation therapy, music therapy…?”
Compliance does not require that the nonpharmacologic approaches be delivered at the hospital. Rather, it makes clear that “the hospital either treats the patient’s pain or refers the patient for treatment.” The document speaks to referring to community licensed practitioners.
Comment: I have two main take-aways from this new guidance. First, this is a historic move. Second, it is unfortunate that the Joint Commission did not empower this change the leverage it deserves. To push their accredited institutions toward a revolutionary “non-pharma first” approach, they would have called more attention to options. They would have done what the Consortium, IHPC, and others recommended their responses to the draft and explicitly mimic the 2015 document and describe a fuller set of non-pharma tools, including “… physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy and music therapy.”
Why did they not specifically name some of these approaches, to get hospital compliance officers’ attention?
Instead, the Joint Commission opted for the bland “non-pharmacologic.” To many medical directors and compliance officers, this is likely to be restricted to behavioral medicine and physical therapy. Similarly, when referencing the partnerships with “licensed independent practitioners” in the community, the Joint Commission might have said “including experts in non-pharmacologic approaches, such as licensed chiropractors, acupuncturists, massage therapists, and naturopathic physicians.”
Off the table altogether, apparently, was the potential of the Joint Commission to mandate that accredited hospitals offer non-pharmacologic approaches in their facilities, or in in-patient care. The march toward optimal pain treatment and against opioid abuse begins at the bedside.
In these ways, the Joint Commission missed an opportunity to truly be a hero in the campaign to transform the nation’s relationship to pain treatment.
That said, the steps the Joint Commission took are potentially quite powerful. They are tools in the hands of integrative care activists, inside and outside of institutions. The Joint Commission language endorses basic tenets of integrative health and medicine. Less invasive, non-pharmacologic methods come first—a transformation of the therapeutic order, as the naturopathic doctors put it. The Joint Commission promotes an integrative model, recommending “a combination of approaches.” In these ways, integrative principles have officially landed in the policing of U.S. medical delivery.