An evidence-based answer to the opioid crisis
by Jonathan Clapp, MD, and J. Scott Bainbridge, MD
Despite substantial efforts to reduce the impact of the opioid epidemic, death rates continue to climb both locally and nationally. According to the Centers for Disease Control and Prevention, in 2016 there were 32,445 deaths nationally involving prescription and illegal opioids, equivalent to about 89 deaths per day. This was an increase from approximately 22,598 in 2015. The Colorado Health Institute’s analysis reveals that in Colorado, 919 overdose deaths were recorded in 2016, and preliminary Colorado Department of Public Health and Environment data from 2017 shows yet another record increase to 959 deaths.
Physicians need to lead
Physicians need to lead the way to eradicate this crisis. The Colorado Medical Society and the Colorado Pain Society have offered insights and helped to guide legislation and other policymaking regarding the best ways to balance the appropriate treatment of pain, while decreasing opioid-related overdoses and addiction.
The solution to this challenge can be found in the evidence; however, physicians have failed to universally adopt it. With two steps Colorado could become not just a national leader but also a national standard if: 1) Physicians are educated on proper diagnosis and better treatment of pain using alternatives to opioids, and 2) Health insurance companies ensure easy patient access to these evidence-based alternatives to pain treatment.
Our institutions have failed to teach us about pain. The American Pain Society published a study that showed U.S. medical schools offered only an average of 11.3 hours of “pain training” in some form compared to roughly 2.5 times that (27.6 hours) in Canada, where the overdose rate per population is roughly 2.5 times less than that of the United States. According to research, pain is the primary reason for all patient visits, but less than 1 percent of our training is dedicated to this complaint. Formal courses (or even single lectures) on pain treatment are uncommon for patients struggling with anxiety, addiction, high opioid tolerance, respiratory compromise and many other confounders. We learn about opioids and their pharmacology, but not how to best diagnose and treat pain and understand the variables inherent to treating patients in pain. Too often, older and cheaper opioids are used as a “fix-all.”
More education available
More than 80 percent of CMS members have already engaged in pain continuing medical education (CME) activities, but we need to take it a step further to eradicate the opioid crisis. Thanks to the Colorado Consortium, CMS and the Colorado Pain Society working together, we have an incredible opportunity to establish multiple web-based, live lectures and resources to educate physicians and pain providers on basic pain concepts like opioid-induced hyperalgesia, opioid-rotations, using safer atypical pain medications like tapentadol and buprenorphine, identifying the type of pain and pain generator, and treating with recommended non-opioids as first line. This would equip providers with alternatives to the more dangerous (but cheaper) generic opioids like oxycodone, morphine, fentanyl, methadone, hydrocodone, hydromorphone and oxymorphone.
Health plans need to step up
Unfortunately, all too often it seems that the use of these dangerous opioids is the only pain treatment that health insurers either consistently cover or do not impose cumbersome prior authorization requirements. Safer and evidence-based, non-pharmacological pain treatments (pain psychology, physical therapy and acupuncture), appropriate interventional procedures, safer atypical opioids (tapentadol IR and ER, buprenorphine buccal films and transdermal patches) and at least one of existing, and future, FDA designated abuse-deterrent opioids for each specific molecule (oxycodone, hydrocodone, morphine, etc.) have to be easily accessible if we are to safely treat pain.
The next step is for the profession to push for insurers to increase their role in solving the opioid crisis. It is not ethical to limit access to pain treatment and doing so only protects their bottom line. The hypocrisy is evident hundreds of times per day in Colorado, when the opioids that are most often abused and responsible for killing our loved ones are the only ones that are affordable for most patients. Or, they have to “try and fail” these dangerous opioids before getting something safer and more specific for the individual’s pain. This leads to greater exposure to the very drugs driving the addiction that is fueling the opioid epidemic.
Posted in: Colorado Medicine | Initiatives | Prescription Drug Abuse