Providers forced to prescribe opioids because health plans give few choices

The opioid epidemic has been likened to the black plague, with the U.S. reaching a peak of 33,000 deaths due to overdose in 2015. With an average death toll of 91 daily, it may shock the public to know that nearly two thirds of these deaths are attributable to prescription painkillers. But what if there are few, if any, affordable options for pain control?

Who or what is to blame for all of these deaths by overdose of prescription painkillers? The blame for the increasingly publicized, public health crisis, shifts. It’s the individuals who are addicted to prescription drugs, those who doctor shop to illegally obtain more opioid prescriptions. It’s the drug manufacturers (Big Pharma) whose marketing practices minimize addiction risk and overinflate health benefits.

{mosads}In fact, at least three states (Ohio, Illinois, and Mississippi, and several individual counties and cities) have filed lawsuits against pharmaceutical companies who make, market, and distribute oxycodone, the most prescribed opioid on the market today. And, now prescribers, who are being pressured to take responsibility, and we agree that providers should prescribe opioids responsibility, but many don’t.

Some prescribers have been arrested and charged for overprescribing or fraudulently prescribing opioids. In other cases, there are well-meaning providers who simply didn’t have the knowledge, so additional training on pain control and opioids has been encouraged, which the Food and Drug Administration offers.

But there is another important factor at play, that is, private insurance companies, and public programs such as Medicaid and Medicare, which regulate what medications providers can prescribe.

Here’s how it works. Each insurance company publishes what is called a drug formulary, a list of medications that are covered for various health conditions. In general these formularies contain limited non-narcotic options for providers to treat patients’ pain. Lidocaine patches for example, can vary from $85 to $280 for a 30-day supply, and are not commonly covered on prescription drug formularies.

Even when a plan will pay for such medications, they require an extensive and arduous prior authorization process for a minimal supply of medication. Drug companies do provide prescription assistance programs, but you have to be low income or uninsured to qualify. This means, that for patients with Medicaid, Medicare, or private insurance, non-opioid options may not be covered by insurance while this same coverage disqualifies them from drug assistance programs. Providers for these patients are in essence pushed toward the opioid option to treat pain.

Likewise, effective non-medication options such as physical therapy, massage, and acupuncture are cost prohibitive due to the way in which private insurance companies provide coverage, if they are covered at all. When they are covered, these options have high deductibles and provide few sessions, which limit their effectiveness.

One large system — The Department of Veterans Affairs — knows better. They know that 60 percent of returning service members from the Middle East with have chronic pain, and they realize the value of non-medication options. An investment of over 21 million in investigating the effects of complementary alternative medicine to treat chronic pain, among other ailments such as PTSD, drug abuse and sleep problems looks at what other interventions are most effective. Maybe others will follow.

The truth is that prescribers are aware of the problem but many times unfairly shoulder the blame because they are not in a position to fix it. They are ethically obligated to treat pain and can only prescribe what a patient can afford. This has frequently become an issue when drug formularies include few if any non-narcotic options to treat pain or entirely ignore non-medication options.

The reality that insurance companies dictate treatment options, often limiting a provider’s choice in addressing pain and thus contribute to the opioid epidemic is largely overlooked.

Public thought leaders and pundits should realize that people have pain regardless of how we treat it, with the Institute of Medicine estimating that about 33% of people have chronic pain, pain that lasts six months or more. Meaning without accounting for the 76.2 million Americans who will experience an episode of acute pain this year, providers will address pain in 1 out of every 3 patients they see in the office.

In these terms, we don’t so much have an opioid crisis as a pain epidemic that we haven’t done a good job of addressing.  

Melissa Kalensky, DNP is a family nurse practitioner and assistant professor, Rush University. Mona Shattell, PhD, RN, FAAN is department chair and professor, Rush University.

The views expressed by contributors are their own and are not the views of The Hill.