pain – M2HCC

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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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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Marijuana During Pregnancy: How Should Physicians Advise Pregnant Women?

By M2|2017-10-08T11:26:51+00:00August 30th, 2017|Evidence-Based Medicine, Uncategorized|

Marijuana During Pregnancy: How Should Physicians Advise Pregnant Women?

As some states have legalized marijuana in recent years, for medical use and/or recreational use, the use of marijuana during pregnancy has also increased; almost 4% of pregnant women said they had used marijuana in the past month in 2014, compared with 2.4% in 2002, according to a recent study published in the Journal of the American Medical Association.

The New York Times recently highlighted the stories of several women who had written in about their experiences taking the drug while they were pregnant; of the “hundreds” of readers who wrote in, “most had smoked, while a few vaped or ate marijuana-laced edibles,” the article says. “Roughly half said they had used pot for a medical reason,” such as nausea or back pain.

“Most felt marijuana use had not affected their children, or were not sure; just a handful worried the children might have suffered cognitive deficits.”

However, the acceptance of marijuana has “outstripped scientific understanding of its effects on human health…Often pregnant women presume that cannabis has no consequences for developing infants. But preliminary research suggests otherwise.”

Indeed, “cannabinoids readily cross the placenta, entering the fetal circulation and brain, and higher fetal levels are seen with chronic use,” Jennifer Gunter, MD, an ob/gyn, points out in a June 2017 commentary.

“Another concern is that doses of THC [tetrahydrocannabinol, the main psychoactive ingredient] in marijuana have increased dramatically, from 4% in 1995 to 12% in 2014, with labs in Colorado reporting THC concentrations in some strains as high as 30%,” Gunter says. “Women choosing to use marijuana in pregnancy will be exposed to significantly higher doses compared with 20 years ago.” Also, “many strains that claim to be high in CBD [cannabidiol, the ingredient that may help nausea and pain] in fact contain little, if any.”

As for the various ways in which marijuana may be taken, “while women may think that marijuana concentrates and edibles are healthier because they do not involve smoking, they can still have significant and potentially harmful solvent residue from processing with chemicals such as butane,” she says.

“The endocannabinoid system is complex and not fully understood,” Dr. Gunter points out. “Animal studies show that prenatal exposure to THC, even at low doses, causes long-lasting neurologic changes among exposed progeny.” And in a recent meta-analysis of 24 studies of sufficient quality, women who use cannabis during pregnancy were found to have an “increased risk for anemia.” That study also found that “fetal exposure reduces birth weight and increases the need for neonatal intensive care unit admission.”

The American College of Obstetricians and Gynecologists (ACOG) recommends asking all women about marijuana use, Gunter notes. “Given the unsubstantiated reports of safety that women may find online, prenatal providers should be prepared to provide clear information about the safety concerns in a nonjudgmental way. It’s important that women get this information from their health providers so that they have accurate data to inform their medical decision-making. Prenatal providers should encourage women to report nausea and vomiting early and not downplay symptoms, as lack of help from traditional medicine may be one reason that women turn to marijuana.”

Gunter notes that ACOG “specifically recommends against advising marijuana use for nausea and vomiting in pregnancy. ACOG also recommends that providers help women who are using marijuana for medical reasons to find alternatives with pregnancy safety data.”

“Discussions about marijuana can be hard as the ‘safety’ of the drug seems entrenched,” she notes. “But I’ve found that many patients are receptive when I explain to them the extremely high concentrations of THC in modern strains, the often low levels of CBD despite advertising to the contrary, and concerns about solvents.”

This discussion highlights the fact that while some patients may assume that marijuana is safe and effective, and the main ob/gyn association recommends its members point patients toward prescription alternatives, the truth is we simply don’t know whether marijuana is safe or effective for pregnant women to treat symptoms such as nausea and pain.

This is yet another example of where data is lacking. What should physicians do in any situation in which there is insufficient data to make a recommendation? The answer as I see it: Admit researchers don’t have the answer yet. Although I realize this may be uncomfortable for many docs, it’s ok to say, “I don’t know.”

What the evidence suggests so far is the potential for cannabinoids to affect the brain and circulatory system of the baby in the womb. Thus, pointing out the potential risks of marijuana use during pregnancy, as noted by Dr. Gunter above, while acknowledging the overall lack of conclusive data, would seem the appropriate approach.

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Coverage Drives Treatment: The Case of Pain

By M2|2017-10-09T01:59:34+00:00March 31st, 2017|Uncategorized, What do we pay for and why|

Coverage Drives Treatment: The Case of Pain

Last week Congress decided not to move forward with repealing and replacing the Affordable Care Act with the American Health Care Act of 2017. This doesn’t mean health reform is over in the U.S., though.

Patient access to care and the costs of that care are still hot topics in Washington, D.C. and statehouses across the country. As we move forward in reform, I would propose a close look at the opioid epidemic and ways we can push for payers to cover treatment that is patient-centered and evidence-based. Seems straightforward, but it isn’t.

A USA Today op-ed from last fall had a subtitle on the opioid epidemic that said it all: “There are other ways to manage chronic pain, but insurance companies won’t pay for them.”

In the summer of 2016 the U.S. Surgeon General sent a letter to physicians in the U.S. basically saying they haven’t been properly trained to manage pain and they could do better to manage patients with pain than just handing over a prescription for an opioid. Dr. Vivek Murthy was more eloquent, writing, “We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic.”

Prescriptions for painkillers vary dramatically by state, further supporting the argument that prescribers may not be following a standard of care for treating pain.

Source: CDC, Policy Impact: Prescription Painkiller Overdoses

It is true that clinicians are uniquely situated to address responsible opioid use and pain management, but that will be difficult to do without support from health insurers. Dr. Robert Bonakdar, the author of the USA Today piece and the Director of Pain Management at the Scripps Center for Integrative Medicine, and immediate past president of the Academy of Integrative Pain Management, succinctly explained the entire U.S. health care system’s approach to pain management:

… many well-established non-pharmacologic treatments like biofeedback and cognitive behavioral therapy (CBT), endorsed [by Murthy], are routinely denied by insurance companies. As an ironic example of the campaign’s shortcomings, on the same day I received the surgeon general’s letter, I received one of the standard insurance denial letters for the biofeedback I had requested for a patient’s headache.

Government agencies and other advisory organizations are coming together to acknowledge that addressing pain is not as simple as writing a script – which is clearly what the system pays for right now.

The National Pain Strategy reminds health care providers and policymakers (and anyone else who will read its 72 pages) that, “Chronic pain is a biopsychosocial condition that often requires integrated, multimodal, and interdisciplinary treatment, all components of which should be evidence-based.”

The Principles of Chronic Pain Treatment prompt health care providers who are treating patients with pain to “use nonopioid therapies to the extent possible,” but also to “identify and address co-existing mental health conditions (e.g., depression, anxiety, PTSD)” in patients in order to best define their treatment needs.

The health care system needs to move in the direction of covering what works. Like other examples we have covered in the Pondering Policy blog, opioids are no exception to the rule.

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