Physician leaders know about the potential dangers of opioid prescriptions for pain, and they’re open to new ideas. But while federal agencies encourage that thinking, they’re not as forthcoming with practical support.
Ann Lindsay, MD, cares for people with complex conditions — people with an average of nine conditions and lots of medications. Often, they have pain. And often, when they first enroll in her clinic, they are on an opioid pain reliever.
So when Lindsay and her husband, Alan Glaseroff, MD, started their clinic at Stanford University in 2011, one of the first things they did was look at their patients’ conditions and try to figure out how to help them most for the least amount of money. After the review, it was clear that pain — and its treatment — was one of the drivers of costs. If they could bring a physical therapist on staff and give patients access in the clinic, they might be able to save the insurance company money and improve the quality of their patients’ lives.
But something else also happened.
“Our prescriptions for opioids went down by at least 50 percent,” Glaseroff says. “That wasn’t our goal. There’s a place for opioids in the world.”
But the role of opioid pain relievers is changing, as the Centers for Disease Control and Prevention set stringent limits on opioid prescribing and insurers set limits on the length a patient can stay on opioids after surgery. As physicians attempt to find the balance between addressing chronic pain and putting their patients at risk for addiction and overdose, many are starting to ask the questions Lindsay and Glaseroff are asking: How do you treat pain without opioids? And which policies can help make such nonpharmacological treatments within reach of their patients?
An Epidemic of Pain and Opioid Misuse
This year brings us to a new intersection of two crises: One, the opioid epidemic that claimed 59,000 lives in 2016. The other, less explosive but still growing, is an epidemic of pain. More than one in three Americans report chronic pain, according to a study a long-term study by the National Institute on Aging and the Social Security Administration.
Pain is not one thing. It often comprises a constellation of sensations, causes and pathologies. People’s sensitivity to pain varies, and can be influenced by things as disparate as adverse childhood events, obesity and lifelong coping mechanisms, Glaseroff says. Recent research indicates chronic pain can have a disease pathology unto itself.
And pain is continuing to grow in a way it didn’t used to. It no longer seems to find a consistent level after age 60, despite the fact that opioid prescriptions increased between 2000 and 2010, from when the data was drawn. But something else was happening while opioid prescribing was rising: Prescribing nonopioid pain treatments dropped by 9 percent, from 38 percent to 29 percent, the study reports.
According to a Georgetown University report, about one in five people with chronic pain have been prescribed an opioid painkiller.
The good news is that there are solutions, though inadequately studied ones. A 2016 Agency for Healthcare Research Quality review found that the strongest evidence of effectiveness in treating acute pain remains superficial heat and muscle relaxants. For chronic back pain, chiropractic treatments, acupuncture and exercise had similar evidence of effectiveness as nonsteroidal anti-inflammatories, opioids, synthetic opioids (like tramadol), SNRIs (like duloxetine) and multidisciplinary rehabilitation.
The evidence for yoga, tai chi and talk therapy was of lower quality, although the National Pain Strategy, a 2011 Department of Health and Human Services action plan, calls cognitive behavioral therapy the “gold standard” for pain management.
Whether certain forms of activity are significantly better than others remains unclear. What is clear is that moving helps, according to a 2016 review in the Swiss journal Healthcare.
But the data are incomplete. For instance, the AHRQ found that few studies evaluated effectiveness of treatments for sciatic and other radicular pain. “Relatively few trials directly compared the effectiveness of different medications or different nonpharmacological therapies, and they generally found no clear differences in effects,” the authors state.
There might be a solution in the National Pain Strategy, however. It calls for several changes, including:
- Increasing funding for research into pain pathogenesis and effective treatment.
- Educating and hiring more mental health professionals to deal with pain.
- Training physicians to manage pain.
- Providing coordinated primary care that’s comprehensive and multimodal, including appropriate use of opioids and management of people with or at risk of substance use disorders, and the use of complimentary therapy and integrative medicine.
- Paying physicians and medical systems for population health in a way that promotes interdisciplinary treatment and care.
Getting Care Covered
Indeed, payment policies affect physicians’ — and patients’ — options. The National Ambulatory Medical Care Survey indicates that physicians prescribed nonpharmacological pain treatments in only 7 percent of visits between 2000 and 2010. This was an increase from 2.9 percent.
A May 2017 report from the Georgetown University Health Policy Institute shows why that might be: One in four marketplace insurance plans limited rehab visits, such as to physical or occupational therapists, to 20 visits or fewer annually. Employer-sponsored plans could cover up to 60 visits, for all types of rehab. Limits on acupuncture and chiropractic are often lower, the report said. Eighty percent of physicians in the report said that their patients had been unable to find mental health care covered by their insurance.
Physicians are seeing a confluence of two events — the ongoing opioid epidemic and a rising number of patients reporting pain. The way the pain is treated is evolving over time.
Only three of the five insurers who spoke to Georgetown researchers were increasing access to nonpharmacological pain treatments. And only one had a comprehensive plan to expand such access.
“Limits on services such as physical therapy, difficulties accessing mental health services, and medical management techniques,” the report states, “create incentives for providers to rely heavily on opioids to treat patients living with chronic pain.”
Those coverage limits are true even at the top. CMS Administrator Seema Verma tells the Physician Leadership Journal that, though the agency is working with HHS and the CDC to work out a plan to address the opioid epidemic, it doesn’t have plans to expand coverage for nonpharmacological treatments for pain.
“We’re looking at all options that are available, but I think the important point [is] that it has to be evidence-based,” Verma says. “That’s where we really look to our partners at CDC and [the Substance Abuse and Mental Health Services Administration] to help us understand that. We want to make sure that before we’re paying for treatments, that there’s evidence behind that.”
The National Pain Strategy recommends increased funding for such research. So far, the plan hasn’t received funding and hasn’t been implemented.
Pain Management Under Fee-for-Service
But reimbursement is also a problem. Many insurers pay so little for mental health services, the Georgetown report states, that their therapy networks are small. Likewise, Glaseroff says, providing comprehensive and integrative pain management in a fee-for-service world is nearly impossible. Pain patients are, by their nature, complex and require time — time primary care providers don’t have if they have to stack patient appointments at 15-minute intervals to cover their expenses.
“If you’re seeing patients in a 15-minute cycle, and everyone who is coming in is already on [opioids], it’s easier to prescribe them than to do anything else,” Glaseroff says.
The other way to think about it is this, he said: In many cases, depending on the contract, a physical therapist could cost $300 a visit. At Glaseroff’s clinic at Stanford, the team gets $287 a month for patients. The numbers just don’t pencil out.
“From a health plan perspective, it’s a huge cost, and we don’t know how to measure effectiveness,” he says. “Plus, some PTs are focused on rehab from surgery, and that’s really valuable. But other PTs throw a towel at a machine and sit there while the patient works out, and then a bill for $300 goes to the health plan.”
Treating Pain — and Despair
Lindsay and Glaseroff’s solution was to walk away from the fee-for-service model. In 2011, they founded Stanford Coordinated Care to provide ambulatory intensive care to the 10 percent of Stanford employees whose care cost 90 percent of the health care spending. The AHRQ has profiled the care center as a leader in providing high-quality complex care for less.
Because their clinic is capitated — that is, they receive a lump sum to care for every patient every month for a year — they can do things like hold hourlong appointments for patients that include physicians, care coordinators, social workers and physical therapists.
There, Bonnie Dundee, an occupational therapist who uses a somatic approach to pain, can meet for an hour a week or more for patients struggling with pain. She works on their alignment and movement. But mostly she says she helps them “reoccupy the parts of themselves that feel good.”
When people are in pain, she said, they often emotionally flee their bodies, so that their only experience of their bodies becomes persistent pain. She helps people work on their perception of pain and tries to assist them with new ways of movement that might alleviate the pain over time. She also works to help people release constantly contracted muscles that are part of a physical expression of anxiety or trauma.
“It seems to be so nice for our [primary care physicians] to be able to tell patients in pain that we have something here for you,” Dundee says. “ ‘Here, go see Bonnie.’ It’s another tool in their box that’s really working and it’s not an opioid. It’s a huge relief for them.”
But even if you’re not in a capitated environment, Glaseroff and Lindsay say there are things you can do to improve patient pain. When Lindsay and Glaseroff ran a private practice in Humboldt, California, they got to know the physical therapists in their areas, and found one who focused on back pain, and another who focused on falls and frailty. “They got 100 percent of our referrals,” Glaseroff says.
And when dealing with pain, Glaseroff says you must deal with what Princeton researchers Anne Case and Angus Deaton have called “diseases of despair”: drug addiction and alcoholism. Because there’s such an overlap between pain and opioid use, Glaseroff says he asks one simple question to assess patients who might struggle with pain and addiction: “How was your childhood?”
Research shows people who experience multiple adverse childhood events are more likely to become addicted to drugs. And because those people may also have physical pain, assessing a poor childhood — one that could be filled with adverse childhood events — is important in how you manage a patient’s pain.
This, Glaseroff says, is where medicine becomes an art. “It’s less modality and more curiosity,” he says. “That’s why it’s so hard to study any of these things, because a lot of it is about the practice rather than what they do. … Two programs can look alike structurally but have different results. I think it may well be more about the soft skills [of the care team].”
Heather Boerner is a freelance health care writer based in Pennsylvania. She covers health law and policy for the Physician Leadership Journal.
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