The current opioid epidemic has “…claimed more lives than the HIV/AIDS crisis at its peak.” Time Magazine, November 13, 2017, p.15. Policy makers have taken notice of the epidemic and state legislatures have enacted various bills over the last year; President Trump declared the opioid epidemic to be a national public health emergency on October 26, 2017, thus creating a 90 day window during which federal agencies my shift part of their existing budgets to address the crisis. After this 90 days, the emergency status can be renewed.
Who is to blame for this epidemic? How about everybody? Maybe it was the opioid manufacturers and their marketing techniques which convinced doctors that the opioids where the solution to chronic pain problems without any noticeable side effects? Maybe it was the doctors who prescribed the opioids without asking pointed questions about addiction? Maybe it was the insurers and pharmacy benefit managers (PBMs) which routinely reimbursed opioid prescriptions and refused to pay for more expensive non-opioid alternatives? Maybe it was government agencies which directed hospitals and physicians to inquire about a patient’s pain at every encounter? Maybe it was the patients who continue to demand the pain relief given by opioids?
The blame game is one thing. However, the real endeavor should be how do we get out of this epidemic? One of the continuing problems in dealing with the opioid crisis is the failure of insurance companies to act responsibly. An article in the New York Times entitled “Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Pain Killers” (September 17, 2017) highlights the problem.
The gist of the article (compiled by NYT and ProPublica, the independent, nonprofit investigative journalism organization) was that more expensive and less addictive pain medicines such as Butrans and Lyrica are not reimbursed but addictive (and cheap) drugs like morphine are routinely permitted. In most cases, the decisions are made by pharmacy benefit managers (PBMs) working for insurers; the 3 largest PBMs being CVS Caremark, Express Scripts and OptumRx which handle 75% of all commercial prescriptions in the United States.
There are number of alternatives to opioids in relieving chronic pain. One is acupuncture which is now being used by the Veterans Administration in all of their hospitals across the country (www.baltimoresun.com/health/bs-hs-veterans-acupuncture-20171226-story.html).
Other alternatives include lesser addictive opioids and allowing doctors to use medication assisted treatment (MAT) to gradually withdraw an opioid addict from his dependence on the drugs. One MAT drug is buprenorphine which can be prescribed without the need for a rigid clinical program for monitoring the recovering addict. It is not without its critics but doctors maintain that medicines like this allow for a gradual withdrawal and are useful in ending the opioid dependence. Studies show that people given medications like methadone or buprenorphine are less likely to overdose or relapse.
In all likelihood there is a subset of individuals with chronic pain that need to be treated with opioids and alternative therapies will not suffice. It should be remembered that one of the reasons and, indeed, the principal reason for the popularity of opioids is that they worked so well in relieving chronic pain. Indeed, they were the first approved medicine which addressed the chronic pain problem. The problem, of course, is that they worked so well that people with chronic pain became overly dependent and addicted to them and that created a whole set of different problems.
A bill to be filed in the Georgia legislature (See Model Legislation) will require health insurers to reimburse for “less addictive opioids” and for cognitive behavioral therapy as well as inpatient and outpatient treatment for whatever time deemed medically necessary by the patient’s physician.
Perhaps the most comprehensive proposal to deal with alternatives to opioid prescriptions is a proposal of the Colorado Department of Regulatory Agencies, Division of Professions and Occupations entitled in “Guidelines For The Safe Prescribing and Dispensing of Opioids”. These Guidelines (Policy for Prescribing and Dispensing Opioids) will now be considered by the affected professional boards but it is likely that the Guidelines will be adopted not only because of their completeness but also because the various boards were represented in the 18 month process leading to the final proposed document.
According to the Guidelines, the decision to prescribe or dispense opioids should be made only after the careful consideration of the benefits and the availability of other treatment modalities including the following (p 4):
- Nonopioid pharmacologics such as acetaminophen, alpha–acting agents, anticonvulsants, antidepressants, nonsteroidal anti- inflammatory drugs (NASIDS), muscle relaxants, or topical lidocaine; and
- Nonpharmacologic treatments such as acupuncture, complementary alternative medicine, cognitive behavioral therapy, dry needling, … or interventional pain management procedures.
These Colorado Guidelines recommend the use of “topical lidocaine” but insurers regularly maintain – without a shred of evidence – that this medicine is no better than BenGay. Doctors and patients who use these topicals are grateful for the relief given – relief that BenGay would never provide.
One apologist for the PBM industry has suggested that PBMs should sue opioid manufacturers for marketing practices that introduced opioids to citizens who were then turned into abusers (a sort of Big Tobacco type of lawsuit now being filed by states and cities across the country). PBMs, it is argued, should sue for opioids they reimbursed because of these marketing practices. The audacity of this suggestion will not be lost on doctors or their patients who daily encounter PBMs routinely authorizing less expensive opioids instead of more expensive non-opioid therapy.