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17 Articles in Volume 20, Issue #1
20/20 with Lynn Webster, MD
Correspondence: Opioid-Induced Hyperalgesia; Pain Care in Older Adults
Don’t Discount the Role of Diet for Chronic Pain Relief
Editorial: Why Haven’t There Been More Breakthrough Analgesics?
Gasping for Air: Sleep-Disordered Breathing and Chronic Opioids
How can botulinum toxin be used in chronic pain syndromes?
Inside the Potential of Peripheral Kappa Opioid Receptor Agonists
Neurodestructive Interventions for Cancer Pain
Obesity and Pain Care: Multifaceted Considerations for Treatment
Obesity and Rheumatoid Arthritis: What Clinicians Should Know
Sickle Cell Pain Crisis: Clinical Guidelines for the Use of Oxygen
The Complexity of Sickle Cell Pain: An Overview
The Perseverance Loop: The Psychology of Pain and Factors in Pain Perception
The Rapid Rise of Non-Opioid Pain Policies
Treating Pain by Overcoming Communication Barriers
Visual Artists Tackle What Pain Looks Like
Will 2020 Be the Year of Patient Education?

The Rapid Rise of Non-Opioid Pain Policies

Legislatures and insurers are crafting policies that encourage, incentivize, and, in some cases, mandate the use of alternatives to opioid pain therapy.
Pages 64-65

Did you know that there is a policy in Delaware that prohibits insurers from imposing numerical limits on physical therapy and chiropractic care visits that might deter prescribers or patients from using those treatments rather than opioids?Or, that, in addition to the 33 states that allow the use of medical cannabis for the treatment of chronic pain (or at least certain pain conditions), New Jersey, New York, and Pennsylvania have approved medical cannabis for the treatment of opioid use disorder?2 Or that a number of licensing boards across the nation are now requiring prescribers to obtain continuing education on non-opioid, non pharmacological, and/or implantable devices for pain management?

It’s no secret that in recent years, as our nation has struggled to tackle opioid overdose and misuse, many hundreds of policies have been adopted at the state and federal level to address issues such as initiating opioid treatment, tapering opioids, morphine milligram equivalent dosages, urine drug monitoring, opioid treatment agreements, and referral to pain and addiction specialists. However, in an attempt to thoughtfully and effectively improve pain care while reducing opioid use, there has also been a rapid rise in a much less talked about, but incredibly important, variety of policies: those that encourage, support, incentivize, and sometimes (but rarely) mandate the use of non-opioid treatments for the treatment of pain.

In addition to ensuring that private insurers are supporting the use of non-opioid therapies, many states have started to focus on improving their own state-based health programs. (Image: iStock)

Improving Coverage of Non-Opioid Treatments

As the national spotlight began to turn toward opioid misuse and overdose, health insurers were quick to do their part in reducing opioid use. Anthem Blue Cross and Blue Shield, for example, implemented policies that limit days’ supply of opioids for acute pain and require prior authorization for long-acting opioid therapy initiation.3 Cigna and Humana, too, have implemented policies that severely restrict who may receive opioid therapy.4,5 While these policies play a key role in reducing inappropriate opioid use, they can also have the effect of reducing treatment options for patients living with both acute and chronic pain.

To ensure that people living with pain are able to access affordable and effective pain care, despite insurers tightening their grip on who may receive opioid therapy, a number of states have implemented policies aimed at improving insurance coverage of non-opioid pain management therapies. In Louisiana, when a physician prescribes a non-opioid medication for the treatment of chronic pain, it is unlawful for a health insurer to deny coverage of the non-opioid prescription drug in favor of an opioid prescription drug.6 In Rhode Island, patients with substance use disorders shall have access to evidence-based non-opioid treatments for pain, including medically necessary chiropractic care and osteopathic manipulative treatment.7

In addition to ensuring that private insurers are supporting the use of non-opioid therapies, many states have started to focus on improving their own state-based health programs. In 2018, Delaware prohibited the state employee healthcare plan from imposing any annual or lifetime numerical limitations on physical therapy or chiropractic care visits for the purpose of treating back pain.8 In Tennessee, state law provides cost-related incentives to the healthcare provider if the provider can demonstrate that the pain relief services provided to the patient had the effect of reducing opioid use.9

This table is not all inclusive.

Of vital importance to the entire nation, the SUPPORT Act, passed by Congress in late 2018, directed the Centers for Medicare & Medicaid Services to issue guidance to all states regarding mandatory and optional items and services that may be provided under their plans for non-opioid treatment and management of pain, including, but not limited to, evidence-based, non-opioid pharmacological therapies and non-pharmacological therapies.10 This guidance will ideally help states to better design their Medicare and Medicaid plans so that patients have access to a full range of therapies to manage their pain.

Changing Provider Behavior with Procedures, Training

While insurance coverage for non-opioids is imperative, that coverage will only be useful to a patient if their healthcare provider understands, and considers utilization of, a broad range of possible treatments for pain.

To support the use of non-opioid treatments for pain, a number of states have implemented policies that encourage, and sometimes mandate, the use of non-opioid alternatives for pain management. Nebraska, North Dakota, and Vermont, among others, require that a practitioner consider utilization of non-opioid alternatives prior to opioid use.11-13 While these policies do not prohibit opioid use, a practitioner must consider non-opioid treatments, and must document such consideration in the patient’s medical record. Taking their policy a step further, actually requiring use of non-opioids, Nevada Medicaid will only allow opioid quantity limits to be exceeded if a patient has chronic pain that cannot be controlled through use of non-opioids.14 Rephrased, a non-opioid regimen must be tried and failed before opioid quantity limits may be exceeded.

Finally, as it has been said many times, every problem looks like a nail when all you have is a hammer. In pain management, of course, this refers to the severe lack of training that most healthcare providers receive in regard to non-opioid methods of pain management. In 2011, a study found that students at US medical schools receive a median of just nine hours of pain management education.15

Given that much of that limited time is necessarily spent on helping students to understand the risks and benefits of opioid therapy, very little time is left for education related to non-opioid treatments. To fill that gap, many states have started to require a variety of pain-related continuing education for healthcare professionals. On January 1, 2020, Minnesota implemented a new policy that requires all prescribers to obtain at least two continuing education credits per renewal period on best practices in prescribing opioids and controlled substances, including non-pharmacological and implantable device alternatives for treatment of pain and ongoing pain management.16

Empowering Patients: Informed Consent, Choice

In addition to improving insurance coverage and changing provider behavior, a number of states have taken action to empower the patients themselves to work with their healthcare provider to tailor their pain management treatment plan to best fit their needs.

In a small number of states, providers are required to inform their patients of non-opioid alternatives prior to initiating opioid therapy. In 2018, the Ohio State Medical Board began requiring physicians to engage in conversations with patients before starting them on long-term medication treatment to ensure that the patient is offered non-opioid treatments when appropriate.17 In July 2019, Florida implemented a similar policy, requiring that prescribers inform their patients of available non-opioid alternatives for the treatment of pain prior to initiating opioid therapy.18 Further, they must discuss the advantages and disadvantages of non-opioid alternatives, provide an educational pamphlet to the patient, and document the non-opioid alternatives considered in the patient’s record.

Finally, in a fast-growing number of states, patients are empowered to refuse opioid therapy entirely through the use of voluntary non-opioid directives, thus opting for a treatment plan free of opioid therapy altogether.19 These directives aim to prevent providers from inadvertently offering certain controlled substances to those who could be adversely affected, as well as permitting patients to proactively inform their provider that they do not wish to receive opioids for any reason. Voluntary non-opioid directives can be an appealing option for patients who have a history of substance use disorder and do not wish to expose themselves to opioids, as well as for patients who are at risk for respiratory depression (and therefore opioid overdose) due to comorbidities and/or other medications. These directives may generally be revoked by the patient at any time.

Taking Action to Improve Policy in Your State

Do you see a policy that you believe would improve your ability to care for people living with pain? Consider being a leader in positive change by helping your licensing board and your elected officials to understand why adopting a specific policy would be important to you and your patients. Further, if you are unsure whether or not a particular policy currently exists in your state, you can contact your licensing board with questions. They may be happy to give you guidance – and perhaps more importantly, hearing of your interest in certain topics may help your state to determine their health policy agendas as they head into the new decade. •

Last updated on: February 3, 2020
Continue Reading:
Reconciling the New HHS Opioid Tapering Guideline with CDC and State Policies
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