Doctors, Patients and Insurance Industry Pose Challenges to Search for Non-Drug Alternatives to Opioids
By Barry Meier and Abby Goodnough, New York Times
A few months ago, Douglas Scott, a property manager in Jacksonville, Florida, was taking large doses of narcotic drugs, or opioids, to deal with the pain of back and spine injuries from two recent car accidents.
The pills helped ease his pain, but they also caused him to withdraw from his wife, his two children and social life.
“Finally, my wife said, ‘You do something about this or we’re going to have to make some changes around here,'” said Scott, 43.
Today, Scott is no longer taking narcotics and feels better. Shortly after his wife’s ultimatum, he entered a local clinic where patients are weaned off opioids and spend up to five weeks going through six hours of training each day in alternative pain management techniques such as physical therapy, relaxation exercises and behavior modification.
Scott’s story highlights one patient’s success. Yet it also underscores the difficulties that the Obama administration and public health officials face in reducing the widespread use of painkillers like OxyContin and Percocet. The use and abuse of the drugs has led to a national epidemic of overdose deaths, addiction and poor patient outcomes.
In recent months, federal agencies and state health officials have urged doctors to first treat pain without using opioids, and some have announced plans to restrict how many pain pills a doctor can prescribe. But getting the millions of people with chronic pain to turn to alternative treatments is a daunting task, one that must overcome inconsistent insurance coverage as well as some resistance from patients and their doctors, who know the ease and effectiveness of pain medications.
“We are all culpable,” said Dr. David Deitz, a former insurance industry executive and a consultant on pain treatment issues. “I don’t care whether you are a doctor, an insurer or a patient.”
Alternative treatments for pain may include chiropractic and osteopathic manipulation, meditation, massage, yoga, acupuncture and cognitive behavioral therapy, which helps people cope with pain by changing how they think about it. Insurance plans may not cover all of these treatments, which vary widely in cost, or impose strict limits on them. Comprehensive programs such as the one Scott attended are expensive, charging $20,000 or more.
Many state Medicaid programs for the poor, while eager to reduce opioid use among their members, have only begun to grapple with whether to cover nondrug treatments for pain, or how extensively to do it.
One exception is physical therapy, which Medicaid is required to cover for members who gained coverage under the Affordable Care Act. But the generosity of the benefit varies by state.
“There are definitely discussions going on about alternative approaches,” said Matt Salo, executive director of the National Association of Medicaid Directors. However, Salo added that such benefits were often the first to be eliminated when program budgets are cut because the treatments are considered optional.
Evidence about the effectiveness of the treatments varies widely, adding another layer of complication. The proof is limited for acupuncture, for example, but better for cognitive behavioral therapy.
The Obama administration recently published a national pain strategy that calls for far more research into alternative pain treatments.
A 2008 study by the Mayo Clinic, though, found that patients who were weaned off opioids and undergo a nondrug-based program such as Scott went through experienced less pain than while on opioids and also significantly improved in function. Other studies have had similar findings.
Still, some insurers will not pay for such multifaceted treatment, questioning both their effectiveness and value.
In addition, patients often resist nondrug treatments. Taking a pill is simply faster and easier than regularly leaving work for physical therapy. Also, the impulse of many doctors is to write a prescription.
The problems started for Scott in 2015, when a driver rear-ended his car. The accident caused back and neck injuries. A pain specialist soon had him on a regimen of two narcotic drugs — oxycodone, the active ingredient in OxyContin, and morphine — which were gradually increased to control his pain. In February, his car was rear-ended again, aggravating the injuries.
Before long, he was taking 30 milligrams of morphine and 30 milligrams of oxycodone three times daily, a combined dosage considered high. He said he thought he was doing fine, but he did not want to work and had little interest in interacting with friends, his wife or his children.
“At the time, I would not have told you that I was dependent” on the drugs, Scott said. “Now, I can say I was extremely dependent and addicted.”
His doctor, a pain management specialist, was satisfied that his pain was under control. But after the confrontation with his wife, Scott agreed to go to a clinic in Jacksonville that specializes in alternative programs. His employer’s insurance paid for the treatment.
Initially, Scott thought the program was a joke. But after he was slowly weaned off opioids during the second week, he began to feel better.
“I woke up on a Saturday morning, thinking I have to do my flexibility exercises, do my stretches,” he recalled.
In the 1990s, insurers often supported programs like the one in Jacksonville. But they soon fell out of favor because the programs varied in quality and there was little data to show their long-term value. In addition, opioids appeared to provide a quicker and cheaper solution.
“Insurers started saying, ‘What the heck, why are we throwing money at a problem?'” said Deitz, the consultant.
Virgil Wittmer, a psychologist who directs the program that treated Scott at Brooks Rehabilitation in Jacksonville, said workers’ compensation plans and some private insurers like Aetna and United Healthcare will cover the program’s costs. But others, like Blue Cross and Blue Shield of Florida, will not.
In a statement, Florida Blue said that while it covered some of the alternative techniques like physical therapy used in Wittmer’s program, it considered other approaches experimental and unproved.
State Medicaid plans typically do not cover interdisciplinary programs. But the scope of the opioid epidemic has prompted some states to experiment with alternative approaches.
Vermont, for example, recently passed legislation that directs officials there to develop a pilot program to offer acupuncture to Medicaid recipients with chronic pain and determine whether it is as effective as or more effective than opioids.
Also, starting next month, Oregon’s Medicaid program will provide acupuncture, chiropractic and osteopathic manipulation, and cognitive behavioral therapy to patients with chronic back pain if such treatments are deemed appropriate after an initial evaluation. Patients with back pain may also include yoga, massage or supervised exercise therapy.
Oregon has “spent a great deal of public money on treatments such as surgery and narcotic medications, without good evidence that they improve patients’ lives,” said Susan Stigers, a spokeswoman for the state’s Medicaid program.
Some private insurers and state agencies are also trying to integrate mental health care into their pain care programs. Some people who have long-lasting or chronic pain have undergone a previous trauma, such as emotional or physical abuse during childhood, and their pain is unlikely to abate without psychological counseling.
“Psychology factors are a major issue,” said Dr. Steven Feinberg, a psychiatrist and pain medicine specialist in Palo Alto, California.
But workers’ compensation insurers are particularly leery of doing so because adopting such strategies could mean paying for psychological treatment for years, said Deitz, the former health industry executive.
Scott said that even with his pain under control, he continued to receive psychological counseling. He said that he realized during sessions with Wittmer that he was taking opioids not only to deal with his pain but also because the effect of the drugs was helping him cope with his underlying history of anxiety.
“The opioids were saying to me, ‘Don’t worry about this, I’ve got it,'” he said. “It made me feel that I was in control, when, in fact, I was not.”
To Learn More:
Opioid Crisis Motivates Hospitals to Reduce Drug’s Use in ERs (by David Porter and Josh Cornfield, Associated Press)
Are FDA Opioid Warning Labels Too Little Too Late? (by Matthew Perrone, Associated Press)
CDC Urges Doctors to Render Prescription Painkillers a Last Resort (by Matthew Perrone, Associated Press)
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