Uncovering the Payor Role in the Opioid Crisis - A. Baxter MD

Addiction is costly to treat and heartbreaking to watch. While the public focuses on pharma accountability and money is allocated for treatment, there is a growing priority on understanding and preventing new addiction. The truth is, the pharmaceutical industry and our reimbursement system influenced not just the spread of opioids, but how our culture understands and treats pain. To right these wrongs, industry needs to prioritize psychosocial and physical solutions for pain, and insurance and Medicare need to pay for them.

Purdue Pharma’s revolutionary marketing helped spread OxyContin at a time when physicians were sensitized to treating pain. HMOs were replacing the intimacy of the patient/physician relationship with a “please the customer” model. More insidious than lasagna lunches, physicians were fed the concept of fast, effortless pain relief. Why bother with more complicated and expensive solutions: when used for pain, opioids weren't even addictive! Chronic pain programs supporting the biopsychosocial model - pain relief requires patience, physical solutions and psychological work - couldn’t compete with the simplicity of an inexpensive pill. Reimbursement for multidisciplinary approaches dried up, and programs closed. The most profound misconception still persists: even short term pain from fractures or minor surgery merits an opioid.

It doesn’t take much to start a habit. The most common prescribers of rapid-acting opioids are dentists, giving young adults opioids for wisdom teeth removal. A JAMA article at the end of 2018 revealed that 5.4% of those prescribed opioids had an opioid use disorder (OUD) by the end of the year, compared to 0.4% who weren’t. Over 1 in 20, for a ubiquitous procedure that commonly hurts for 2 days. Specific genetic markers predispose for opioid addiction, and duration matters: while OUD jumps to 13.5% for adults prescribed opioids for 8+ days, the risk of addiction after even three 3 days is 6%.

The inclusion of the NOPAIN act in the 2023 budget and the Draft report from the Pain Task Force  released April 2 are signs of progress in PREVENTING opioid addiction. The former limits home opioid use to seven days for acute pain (without prohibiting relief for chronic conditions). The Pain Task Force gap analysis gives hope because its “initial key concepts” acknowledge that a balanced biopsychosocial model is most effective, and that individualized care taking social and family history into account is critical both for pain and for opioid stewardship. The blind spot in both is that our system continues to pay for pain pills, not pain relief.

80% of those with opioid use disorder began with pills legally put in circulation for pain, paid for by Medicaid or insurance. For initial recreational opioid use, the primary source is friends and family. Eliminating this "medicine cabinet" source is crucial. Now that pills are harder to get, convincing people to throw away the remainder after they no longer need them is even harder. People want to keep a few tabs of “the good stuff” around… just in case.

The Pain Task Force acknowledges this to a certain extent, pushing for balanced pain management. “Balanced” means “opioids and other stuff”, with complementary, behavioral, and alternative medicine on the other end of the teeter totter. What even doctors often don’t know is that for short acute pain, opioids are NOT the best for pain. Take oral surgery again – an analysis of multiple studies found that on average ibuprofen reduced pain 4/10, opioids 2/10, and placebo 1/10. The same was found in multiple studies on post-fracture recovery: codeine and Lortab were no better than ibuprofen, and added side effects. Opioids shouldn’t be an answer to acute pain, they’re the problem.

Post surgically, we now have very long acting local anesthetics. In Japan, patients don’t even get opioids for home after knee surgery. Pain management has become conflated legislatively with pharmaceutical prescriptions. Doctors debate whether they should recommend supplements or products, oblivious to the fact that pharmaceuticals ARE products. While many supplements and devices have rich research support, there isn't a yoga lobby teaching residents how stretching reduces pain. When bills and policies are only about opioids, they shut the door on discussing and disseminating comprehensive pain relief.

To prevent addiction, we need to get everyone below 4 days of opioids for acute pain; for minor acute pain, we need to give people pain relief options to avoid opioids altogether. A recent pilot of a cold/vibration device after knee surgery reduced opioid use 35% - compared to a cohort getting opioid reduction coaching. By their 4 day office visit, 71% had quit taking opioids. A 2013 mastectomy study found magnesium reduced oral opioids from 30mg opioid equivalents to 10mg. But here’s the rub: neither cryovibration nor magnesium are covered by insurance. And few doctors know to tell patients these options work.

What works for pain: it turns out pressure, stretching, motion and touch all inhibit pain strongly in the spine. Cold and magnesium supplements each reduce pain up to 30%, and when the cold is intense (e.g. ice) a feedback loop inhibits pain everywhere, not just at the site. Because the part of the brain that processes pain is easily distracted, anything from conversation to games to activities can reduce the perception of pain while waiting for the body to heal. Sleep hygiene is an integral part of pain relief. And the “individualized, patient-centered care” isn’t lip service – building your own pain plan before surgery enhances a patients’ likelihood of compliance, just like building an IKEA product makes it more special to you. By creating the artificial dichotomy of opioids and “complementary” medicine, a necessary comprehensive solution is missed.

Both the McCain Bill and the Pain Task Force report skirt the pharma-focus that fuels our addiction crisis. Pain matters; pills should be an option, not a single solution for pain. But until we pay for comprehensive pain management rather than pills, those least able to pay for anything but subsidized opioids will suffer. 

Purdue just had a $270M judgement against them. The New York AG just filed suit against multiple industries, likely to generate more penalties. Money can't replace the lives lost to addiction, but putting this money toward pain solution devices that will replace opioids - for dental work, for fractures, for minor surgery and any outpatient injury- will be a step in the right direction to preventing addiction in the first place.