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Treatment Effect Level of

Evidence
Tai Chi Small but clinically significant short term Low
benefit in pain and function
Yoga Inconsistent evidence Low
Exercise Non-clinically significant improvement in pain Low to
(S) and function (S,I) Moderate
Acupuncture Small, non-clinically significant improvement Low
in function (S,I)
Interdisciplinary Clinically meaningful improvement in function Low
rehab in the short, intermediate, and long term

Mindfulness No clear improvement in function or pain Moderate


Massage/PT Small, non-clinically significant impact on Low
short term function; insufficient evidence of
impact on pain
CBT Small, non-clinically significant effects on Low
pain, function and mood immediately post-
treatment but not intermediate or long term
Pain Education No improvement in pain or function Low

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Drug Effect Level of
Evidence

Milnacipran Improves pain and function by 30% or Low


(Savella) more (NNT 5-11)

Duloxetine Improves pain and function by 30% or Low


(Cymbalta) more (NNT 5-11)

Pregabalin Improves pain 30-50% (NNT 7-22) Low


(Lyrica)

opioids Small, non-clinically significant short- High


term improvement in pain and
functioning

Insufficient evidence of benefit for Insufficient


long-term prescribing

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Harms of Therapies

Therapy Harms
Non-pharmaceutical therapies Few if any
(eg PT, CBT)
Non-opioid medications (eg Sedation, weight gain, nausea
pregabalin, duloxetine)
Opioids Constipation, fatigue, dependence,
overdose, opioid induced hyperalgesia,
death

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MED report on opioid tapering

• Overall quality of the evidence is very low


• Findings suggested that pain, function, and
quality of life might improve during and after
opioid discontinuation or dose reduction
• Scant evidence on harms associated with
tapering strategies

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Options for HERC Consideration
• OPTION: Do not reprioritize chronic pain syndrome,
fibromyalgia and related conditions due to lack of evidence of
effectiveness of available treatment modalities. Consider
readdressing the prioritization of these conditions as part of
the 2022 or 2024 Biennial Review.
– Rationale:
• Low level of evidence of small, non-clinically significant
effectiveness of various therapies
• Wait for studies on back line changes
– Impact:
• Continued HERC intent of non-coverage for various
treatments and medications (including opioids) for these 5
conditions

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Options for HERC Consideration
• OPTION: Adopt the CPTF informed proposal from January with
consideration of VbBS/HERC staff suggested edits
– Rationale: Chronic pain patients would have access to
alternative therapies to opioids (physical treatments,
pharmaceutical options). The Chronic Pain Taskforce felt these
were beneficial treatments in their expert opinion.
– Impact: New coverage would be created for nonpharmacologic
and pharmacologic treatments for patients with these specific
chronic pain conditions, including new coverage of long-term
opioid therapy if patients meet certain criteria. This will have
cost implications which will require actuarial analysis.

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