Health Insurers May Play a Substantial Role in Opioid Crisis
Prescription drug monitoring programs are central to federal and state policy responses to address prescription abuse. They are state run electronic database s of prescription medications. Unfortunately, even with these programs in place, there is evidence of limited benefit. Finds of the study suggest drug monitoring programs have a limited impact on individual level opioid utilization. They agree that further studies are needed (Moyo, 2017).
In 2007 there was an article published that stated if the doctors and nurses could get over their fear of opioids there would be an improvement in pain management. Now it is looking like less is more in the use of narcotics. Even short-term use of an opioid can actually aggravate the pain due to an acute-tolerance. In 2014, 16,790 deaths were reported in the US secondary to overdosing with prescription narcotics. It has also been shown that opioids are not always beneficial for chronic pain as originally thought.
It was found, in fact, their quality of life for those with chronic pain failed to improve despite the increase in dosage over a period of five years. In a call from the Surgeon General to limit opioid use in this country, it has been recommended to follow Centers of Disease Control and Prevention (CDC) guidelines for prescribing opioids. This totally ignores the effectiveness of alternative pain therapies. Acupuncture, electro-analgesic, old laser therapy all provide pain relief without opioid use.
The healthcare industry doesn’t help the cause as they tend to either not cover alternative therapies by insurance or limit the coverage of them. Recent articles have noted a new paradigm for treating opioid addiction but continue to use some form of opioids in the treatment. Unfortunately, this is a predictable solution from the pharmaceutical industry. They continue to add on to treat the side effects rather than find alternatives. Because of this practice attempts to curb the present drug abuse crisis is not well served by pharmaceuticals developing novel opioid-related drugs (White, 2018).
Using nationwide insurance the claims as a data set, this study identified US adults 18-64, without opioid use in the year prior to surgery. Millions of Americans undergo surgery each year. Many patients are first exposed to opioids after this surgery but persistent use after surgical care has not been well studied. Specifically, the effect of surgical case mix and other preoperative risk factors remain unclear. The study looked at 13 common elective surgery procedures and split them into minor and major procedures.
Minor procedures were like; varicose vein removal, laparoscopic gallbladder removal, laparoscopic appendix removal, hemorrhoid removal, and carpal tunnel. Major procedures were like; ventral hernia repair, colectomy (removal of part of the colon), reflux surgery and hysterectomy (removal of female reproductive organs). 36,177 patients were used for the study with 80% (29,068) undergoing minor procedures and 20% (7,109) undergoing major procedures.
While the incidence of filling prescriptions was statistically insignificant between the two groups, the study found tobacco use, alcohol, and substance abuse disorders increased the risk of new opioid use. Given the declining rates of morbidity and mortality after common elective surgeries, new persistent opioid use represents an important, common, and under-recognized complication of peri-operative care.
The study suggests that more than two million individuals may transition to persistent opioid use after elective surgery each year. This study also noted that prolonged opioid use after surgery may not be simply a consequence of poorly controlled pain. Because opioids have been termed painkillers, some patients will sue them for conditions not related to surgery. In addition, psychiatric conditions like depression are associated with long-term opioid use but are not generally explored (Brummet, et al 2017).
For many years low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. Musculoskeletal diseases are second only to mental disorders in recent years as a cause of early retirement due to loss of the ability to work.
The new German Disease Management Guidelines on non-specific back pain includes new elements. Among them are psychological and workplace factors and emphasis is given to discouraging multiple imaging and early multidisciplinary assessments are encouraged early in a treatment plan. The study showed there was a benefit for patients whose activities of daily living were restricted and also had inadequate pain relief to be part of a multidisciplinary assessment. In the outpatient setting the principles of multidisciplinary assessment are best met by combining the diagnostic expertise of the doctor, physical therapist, and psychologist.
The study also found programs for strengthening and stabilizing the musculature seemed to help the lower back pain. It was felt from the study that treatment with drugs is purely symptomatic. Treatment for acute pain with drugs is used in a support measure. For chronic pain, is better treated with non-opioid medications such as NSAIDs. COX-2 inhibitors can be utilized if the NSAIDs are contraindicated or poorly tolerated.
Opioid use for acute low back pain should only be used on a case by case basis and only after non-opioid medications are either contraindicated or are found to be ineffective. In addition, this need for opioid use should be reevaluated at least every four weeks. If after this time period relief has been achieved without causing major side effects then continued use could be recommended but they need to be followed closely (Chenot et al 2017).
Abuse and misuse of prescription opioids is a significant public health concern. Appropriate and adequate treatment of moderate to severe acute and chronic pain continues to be an ongoing challenge. While there is a need for treatment of pain with prescription opioids there is a legitimate need to address the challenge.
A balance needs to be found between accesses to properly prescribed opioids and approaches to decrease the ratio of non-medical opioid use, abuse, and overdose. The CDC in the US states the annual opioid prescribing rates increased from 72.4 to 81.2 prescriptions per 100 people between 2006 and 2010, they were constant between 2010 and 2012, decreased by 13.1% to 70.6 per 100 people from 2012 to 2015. Despite the decreases, the numbers of opioid prescriptions in 2015 were three times more than the amount of prescribed in 1999.
This increase has resulted in an increase in prescription of opioid-related overdose deaths (over 15,000 in 2015) and an increase in the diagnosis of opioid-use disorder (addiction) associated with prescription opioids (approximately 1.8 million in 2016). Addressing this issues is multifaceted requiring all stakeholders to be on board to help devise abuse-deterrent formulations (ADFs) of opioids.
As it has been seen in other studies, part of this issue is prompted by insurance companies being unwilling to cover alternative treatments for treating pain. This can be non-drug or medication other than opioids. Oxycodone was one of the first narcotics to be adjusted by the FDA (food and drug administration). It has been reformulated to make it resistant to tampering for use as a recreational drug.
Targinq ER is a medicine that combines oxycodone with naloxone-an antagonist that blocks the euphoric effects of oxycodone if it is crushed for recreational use. These are just the beginning of steps being taken by FDA to limit opioids susceptibility to recreational use. But there is so much more to do other than simply altering the narcotic. Insurance companies need to be receptive to covering non-drug treatments for pain, especially chronic pain (Pergolizzi, 2017).
Public and private insurance policies in the US are missing important opportunities to encourage the use of physical therapy, psychological counseling and other non-drug alternatives to opioid medication for treating lower back pain. This study looked at Medicaid, Medicare, and major commercial insurers 2017 policies for non-drug options. They found that insurers have inconsistent policy terms for non-drug treatment. They provide little or no coverage for interventions that are treatments with a scientific basis.
The study found an important opportunity for insurers to broaden and standardize their coverage of non-drug pain treatments. This would offer patients a safer option than taking opioids. CDC officials estimate 49,031 Americans died from opioid overdoses in the 12 month period ending December 2017. In 2016, an increase of 40% of those deaths was from prescription opioids. In fact, current guidelines from the CDC note that non-opioid pain relief is preferred for chronic pain; outside of active cancer, palliative and end-of-life care.
The study looked at total of Medicaid, Medicare Advantage and commercial insurance plans for 2017 covering non-drug treatments. These plans were applicable in 16 states and chosen for their geographic diversity, wealth, and opioid-epidemic impact. Of the Medicaid plans only three covered psychological interventions. And the study further found that physical therapy-a well-established method of relieving lower back pain while being covered by nearly all plans the amount of coverage varied from two visits to requiring a referral from a doctor. Clearly, the insurance companies including Medicare and Medicaid have a long way to go (Heyward et al, 2018).
Brummett, C.M. et al (2017). New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery,152(6).
Chenot, J. F. et al (2017). Non-specific low back pain. Translated from German by Ethan Taub, MD. Deutsches Ärzteblatt International,114(51-52).
Heyward, J. et al (2018). Coverage of non-pharmacologic treatment for lower back pain among public and private insurers in the US. John Hopkins Bloomberg School of Public Health.
Moyo, P. (2017). Impact of prescription drug monitoring: Implementation and rigor on prescription opioid utilization in Medicare.
Pergolizzi, J.V. (2017). Abuse-deterrent opioids: An update on current approaches and conciderations. Current Medical Research and Opinions,34 (4).
White, P. (2018). An alternative approach to solving the opioid epidemic: Is there a role for non-pharmacologic analgesic therapies? Postgraduate Medicine. Taylor & Francis.