Chronic pain

What gets prescribed and why: Opioids v. obesity meds

By M2|2018-12-06T18:37:08+00:00December 6th, 2018|Chronic pain, Evidence-Based Medicine, Health Care Trends, Insurance, Uncategorized, What do we pay for and why|

What gets prescribed and why: Opioids v. obesity meds

The U.S. health care system doesn’t always make sense. Sometimes, even when there is some logic to it, the reasons underpinning what gets prescribed by practitioners and covered by insurers are disappointing. Two pieces I read recently provide examples.

In one study, we learn that while primary care physicians are prescribing opioids less often, other specialists and nurse practitioners are prescribing them more often. Ultimately, opioid prescribing remains at a high level, despite known issues with misuse and abuse, and the availability of alternative pain treatments.

At the same time, while 40% of U.S. adults are obese, fewer than 2% of obese patients are offered medications for obesity, and ultimately “only about 1% of eligible patients fill a prescription for a weight loss medication.” Even when weight loss medications are prescribed, it is usually for a specific (fairly short) period of time, explained Dr. Caroline M. Apovian, a Professor of Medicine and Pediatrics, Department of Medicine, Section of Endocrinology at Boston University School of Medicine and the Director of Nutrition and Weight Management, Department of Endocrinology, Diabetes, and Nutrition, at Boston Medical Center, in an opinion piece in Medscape.

This is an example of what we like to call at M2: “what do we pay for and why?” If 40% of the public has a disease, why aren’t treatments prescribed and covered? Several chronic obesity management medications have been approved by the U.S. Food and Drug Administration (FDA) in the past few years, and have proven of efficacy of 5%-10% weight loss, but Dr. Apovian argues that “public perception of obesity as a matter of will power rather than a disease” is a key barrier to lower treatment rates for obesity.

The U.S. health care system doesn’t necessarily pay for what works, or the treatments people need. As with all policy decisions, there is a judgment about who deserves what, and who should pay for it. In the case of treating obesity with a prescription, Dr. Apovian succinctly explains the current policy stance: “If obesity is considered a moral failing, why treat it with a pill or surgery?”

What’s the hold up? Why do physicians not turn more frequently to the known effective treatments for obesity? Well, sometimes it is lack of proper training (discussed in our in April). Physicians have a lot to stay up to date on, and obesity treatments are often not prioritized despite the prevalence of comorbidities. As we discussed in a back in February, improved insurance coverage for proven effective weight loss treatments could help avoid expensive complications from obesity down the road and may improve quality of life. We suggest this is a better way to choose what is covered the current approach.

Pain affects a large number of people in the U.S. as well – more than 100 million adults. Nearly 40 million adults experience the highest levels of pain (category 3 or category 4), and there are more than 25 million adults who report chronic (daily) pain. Further, the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain is clear: “Opioids are not first-line or routine therapy for chronic pain.” Despite this clear recommendation, as the recent study confirms, opioids continue to be frequently prescribed for pain, even though there are less addictive alternatives available. These medications aren’t that expensive so are frequently covered by insurance.

The M2 blog, Coverage Drives Treatment: The Case of Pain explains how insurance companies seem to prefer to cover what is inexpensive, and perhaps less effective, at least when it comes to opioids for pain.

Confounding situations like this are when we understand why an overhaul of the health care system is appealing to some. It would be an incredible opportunity to step back and create a new system that approaches all situations – obesity, pain, everything – from the perspective of longer term effectiveness. Ultimately this would reduce health care system costs overall, as less time (and money) would be spent covering up symptoms of something that is likely to cause greater expense down the road.

But in order to do this, we’d have to face who we think deserves what kind of care. These decisions are baked in to the system we have and rarely discussed. 2019 is around the corner. Should we start this conversation in the new year?

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Want to Fix the Opioid Crisis? First, Think Structurally

By M2|2018-05-17T16:49:16+00:00May 17th, 2018|Chronic pain, Evidence-Based Medicine, Insurance, Public Health, Social Determinants of Health, Uncategorized, What do we pay for and why|

Want to Fix the Opioid Crisis? First, Think Structurally

I am often asked to come up with creative ways to address various health care problems. When I was asked by a client a few years ago to come up with some ideas to address the opioid crisis, I dove in to the latest academic literature, news reports, and books (if you haven’t read it yet, and are interested in the bigger picture of opioids, check out Dreamland by Sam Quinones). Thousands of pages later, I came to what seemed an obvious conclusion: opioid misuse and abuse is not a singular crisis, but the effect of a huge set of policy decisions that have occurred over years.

In a recent commentary in the American Journal of Public Health, author Nabarun Dasgupta of the University of North Carolina, Chapel Hill, and colleagues are blunt – “The structural and social determinants of health framework is widely understood to be critical in responding to public health challenges. Until we adopt this framework, we will continue to fail in our efforts to turn the tide of the opioid crisis.”

Using a structural framework to analyze causes of the opioid crisis generates “an alternate hypothesis…that an environment that increasingly promotes obesity coupled with widespread opioid use may be the underlying drivers of increasing White middle-class mortality,” the authors point out. “Complex interconnections between obesity, disability, chronic pain, depression, and substance use have not been adequately explored.” Also, suicides “may be undercounted among overdose deaths,” they say. “Under both frameworks, social distress is a likely upstream explanatory factor.”

In order to “turn the tide” on the opioid crisis, the authors urge a focus on patient suffering, tied to things like social disadvantage, isolation, and pain. However, one of the challenges is that the U.S. health care system is “unprepared to meet the demands elucidated by a structural factors analysis.”

Again, seems obvious, but still bears repeating: the health care delivery system is not built to deal with structural problems.

Addressing these types of factors requires “meaningful clinical attention that is difficult to deliver in high-throughput primary care.” Indeed, the current “institutional, legal, and insurance architecture have robbed clinicians of time and incentives to continue care for these patients,” the authors say.

Incorporating social determinants of health (SDH) into care plans also highlights the need to “integrate clinical care with efforts to improve patients’ structural environment,” the commentary says. While the commentary authors recommend, “Training health care providers in ‘structural competency’” as promising, as the system scales up “partnerships that begin to address upstream structural factors such as economic opportunity, social cohesion, racial disadvantage, and life satisfaction,” I’m not as inclined to think health provider training alone will suffice. When I was first taught the basic premises of SDH and structural thinking as a young graduate student, the discipline was already decades old.

Knowing the importance of SDH is not enough. Until the evidence base is deeper, it is difficult to get payers to reimburse such as activities. (See next week’s blog for a great example though!)

Thinking structurally is not so difficult to learn, but acting structurally is extremely difficult. Still, the opioid crisis – like so many health care conundrums – can’t be solved without it. Let’s get to it.

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An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

By M2|2018-04-10T19:27:24+00:00April 10th, 2018|Chronic pain, Evidence-Based Medicine, Health Disparities, Insurance, Social Determinants of Health, Uncategorized, What do we pay for and why|

An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

Pain is a common, yet difficult to treat condition; it is one of the top reasons people go to the doctor. Opioids are commonly prescribed to treat pain; opioids are quite effective but addictive. The use of cognitive behavioral therapy (CBT) is known to be efficacious in addressing chronic pain; however, its benefit in disadvantaged populations is not well understood.

To help shed light on this question, a team led by Beverly Thorn, University of Alabama, conducted a study to evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care.

The randomized controlled trial enrolled 290 adults with chronic pain symptoms. Most had incomes at or below the poverty level, and about one-third read below a fifth grade level. Many participants were taking opioids at the beginning of the study.

Both the CBT and EDU were delivered in ten weekly 90-minute group sessions. Participants in all three groups reported their pain levels and physical functioning via questionnaires at baseline, ten weeks, and six months.

The study, funded by the Patient-Centered Outcomes Research Institute and published in the Annals of Internal Medicine, found that patients in the CBT and EDU groups had greater decreases in pain intensity scores between baseline and post-treatment than participants receiving usual care.

However, while treatment gains were still present in the EDU group at six-month follow-up, these gains were not maintained in the CBT group, Thorn, et al., say.

Regarding the secondary outcome of physical function, those in the CBT and EDU interventions had greater post-treatment improvement than patients who received usual care; this progress was maintained at six-month follow-up. Changes in depression, another secondary outcome, did not differ between either the CBT or EDU group and those receiving usual care, the researchers state.

This study highlights the fact that when done correctly, i.e., when materials are adjusted and tailored to a patient’s reading level, there are non-opioid interventions like behavioral therapy and education that work. While it is probably easier to prescribe opioids for pain, given the increasing severity of the opioid addiction epidemic, insurers really should consider these effective alternative treatments which positively impact pain. Why NOT prescribe effective, non-addictive treatment whenever possible?

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Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

By M2|2017-10-08T11:16:59+00:00September 28th, 2017|Chronic pain, Evidence-Based Medicine, Health Disparities, Uncategorized|

Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

Headaches are one of the main reasons patients seek health care advice, and racial and ethnic differences exist. For example, migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life versus non-Hispanic whites. Given these disparities, researchers at the University of Michigan set out to determine whether there are also racial differences in the quality of migraine treatment.

In a study published in Cephalalgia, researchers reported that approximately 40% of patients received no preventive medications – prophylactic treatments – though that is the recommended approach for most patients. Further, “among patients that receive a prophylactic agent, it is almost twice as likely that they will receive exclusively agents with low-quality evidence as it is that they will receive agents with only high-quality evidence.”

As for race or ethnic differences in prophylactic treatment, however, patients were treated similarly: 41.3% of African Americans (AA) received no prophylactic treatments from 2006 to 2013, compared to 40.8% of non-Hispanic whites (NHW), and 41.2% of Hispanic (HI) patients.

For patients who needed first-line treatment (also called “abortive treatment”), as with preventive medication, the University of Michigan researchers did not find relevant differences across ethnicities or races, but they did find nearly 40% of patients did not receive a first-line treatment when it was indicated. And similar to the prescribing pattern for preventive medications, when a first-line treatment was prescribed, it was more likely to be one with low-quality evidence.

“This shows an underuse of medications with high-quality evidence,” first author Larry Charleston IV, M.D., M.Sc., an assistant professor of neurology at the University of Michigan Medical School said. “Even for patients being prescribed an abortive medication, we found 27 percent of them were given at least one low-quality abortive medication. Better options do exist.”

The data “suggest that there are major opportunities to improve the quality of headache medication prescribing in the United States, as less than a quarter of migraine patients received all high-quality abortive or prophylactic medications.”

Perhaps most disturbingly, migraine patients “receive prescriptions for opioids about as commonly as they receive prescriptions for medications with high-quality evidence for migraine treatment,” the researchers found.

Looking at the use of opiates, 15.2% of all patients had a prescription for opiates, but there were no racial differences, Larry Charleston and James Burke, University of Michigan, say. In other words, the “investigation into racial disparities in migraine treatment came up empty, but instead it found a different concern that reaches across populations” – opioid overuse, as noted in an article in Lab Report.

The findings on opioid overuse come at a time when opiate-related mortality is “rapidly increasing in the United States,” the study authors note.

“The argument against opiate use for migraine is strengthened by the observation that it is associated with more severe headache-related disability, symptomology, comorbidities (depression, anxiety, and cardiovascular disease and events), greater need to see health care providers and high risk for medication overuse headache. Moreover, most evidence suggests that opiates are, if anything, less effective than non-opiate alternatives,” according to the researchers.

“Given the considerable risks of opiates and the lack of evidence of increased efficacy, opiates should be used rarely, if ever, for migraine,” they conclude. “Interventions to reduce opiate use in the migraine population are urgently needed.”

This overuse of opiates and underuse of less risky, more effective therapies is another example of practitioners ignoring evidence-based medicine. What’s different about this particular example is that it involves opioids, at a time when the opioid abuse crisis has become so critical that the President recently declared it a national emergency. This seems to be an area ripe for educating physicians or for health plans to provide appropriate parameters for prescribing of migraine therapies, to ensure opioids are prescribed only for patients who truly need them.

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Chronic Knee Pain: Internet-Delivered Exercise and Pain-Coping Skills Work Well for Patients, But Will Payers Cover It?

By M2|2017-10-09T01:54:34+00:00April 27th, 2017|Chronic pain, Evidence-Based Medicine, Reimbursement, Uncategorized, What do we pay for and why|

Chronic Knee Pain: Internet-Delivered Exercise and Pain-Coping Skills Work Well for Patients, But Will Payers Cover It?

Knee pain has increased in the past 20 years, and researchers have connected this increase to aging and obesity. Perhaps more importantly, the increasing prevalence of knee pain has led to a surge in knee replacements. This highlights the growing need for effective, accessible treatments to manage chronic knee pain on a population level. In light of this need, researchers at the University of Melbourne conducted a study of Internet-delivered exercise and pain-coping skills training.

The study, published in the Annals of Internal Medicine, found that for people with chronic knee pain, Internet-delivered, physiotherapist-prescribed exercise and pain-coping skills training (PCST) provide “clinically meaningful improvements in pain and function that are sustained for at least 6 months.”

The Internet-delivered interventions included seven videoconferencing (Skype) sessions with a physiotherapist for home exercise, a PCST program and educational materials, delivered over a period of three months.

At three months, the intervention group reported “significantly more improvement in pain” compared to the control group, Kim Bennell, Centre for Health, Exercise, and Sports Medicine, University of Melbourne, at al., say.

The intervention group also showed improved physical function versus the control group and improvements were sustained at nine months.

The intervention group also reported high levels of satisfaction, and had high rates of completion; 78% accessed the educational materials, with an average of 6.3 of seven Skype physiotherapy sessions completed, and an average of 6.4 of the eight pain management modules completed.

This study sheds light on an important challenge for the U.S. health care system; chronic knee pain, is “associated with significant disability and decreased quality of life,” as noted in an accompanying editorial by Lisa Mandl, Hospital for Special Surgery/Weill Cornell Medicine.

“With the aging of the U.S. population, the medical community has braced itself for a tsunami of elderly patients with chronic knee pain – a reasonable response to the projection that almost half of U.S. adults will develop osteoarthritis in at least one knee by age 85 years,” she says. In addition, 50% of people with symptomatic knee osteoarthritis are younger than 65.

“These patients will need effective pain therapy for decades,” Mandl says. “Because osteoarthritis currently has no cure, these demographic characteristics guarantee that a large and diverse cohort of patients will be seeking treatment for chronic knee pain well into the foreseeable future. Therefore, there is a clear and pressing need to identify effective, inexpensive, and low-risk strategies to improve pain and decrease disability in these patients.

The results are also interesting given that “existing therapies have many drawbacks,” as noted in this article on the study. For example, current treatments have adverse effects or may be “cost prohibitive,” and “non-pharmacological therapies, such as physiotherapist-directed exercise and pain-coping training, may be difficult to access, especially for those in rural areas.”

“These results are encouraging and show that ‘telemedicine’ is clearly ready for prime time,” the study authors say. “An Internet-based intervention circumvents multiple issues related to access to care, making this an inexpensive and easily scalable option for people living in remote areas or any location with an inadequate supply of health care providers.”

This study is an excellent example of evidence-based medicine; the Internet-delivered intervention is a low-risk approach that is clearly preferable to knee surgery, and one that improves access for patients, particularly those in rural areas. However, the key questions are: Will U.S. insurers pay for it? And will physicians be willing to perform this service?

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