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Why Insurance Companies are Saying No to Opioid Alternatives

Published September 4, 2017
| Written By SpineNation Editorial Staff  

In 2015, more than 52,000 people died from a drug-related overdose. Nearly two-thirds of those people died because of opioids such as OxyContin, heroin, and Fentanyl. Those drug-related deaths surpass the number of deaths from car crashes and gunshot wounds combined.

Drug overdoses were responsible for more deaths in 2015 than HIV/AIDS at its 1995 peak. And just as HIV/AIDS live on through the American mind as an awful epidemic, the opioid crisis will too.

And here's why.

Prescriptions were encouraged by doctors and handed out without question to patients with long- and short-term pain — though these doctors were not acting impetuously. In the 1990s, a marketing campaign led by Purdue Pharma promoted the widespread use of opioids to treat pain with "minimized risk of addiction."

"We, doctors, were wrong in thinking that opioids can't be used long-term," spoke Dr. Alan Spanos of Purdue Pharma in an HBO Documentary called This Drug May Kill You, that featured the commercial published in the 90s. "They can be and they should be. We used to think they'd stop working or the patients would become addicts or they'd be sedated into inactivity."

The screen cuts to a teenage female sitting on a bus, nodding out from taking pills while people stare and ask if she's dead.

"We now find that these medicines are much safer, much more powerful, much more versatile than we used to think, and we feel that they should be used much more liberally for people with all sorts of chronic pain," said Spanos.

Flash forward to today. Those “safe and powerful drugs” are taking thousands of lives and some of those lives are chronic pain patients. We, as a unit of chronic back pain warriors, need some form of pain relief in order to have a decent quality of life. Are we right Backers?

And more people than ever are aware of this epidemic so why are opioid alternatives for pain management so hard to come by?

Diving In

Michael E. Schatman, the creator of the Foundation for Ethics in Pain Care located in Bellevue, Washington, reported in an issue of the U.S. National Library of Medicine where he wrote, "In the interests of cost containment and profitability, the health insurance industry has contributed to the opioid crisis in the U.S.A. by refusing to pay for therapies to reduce the harm associated with opioid prescribing."

So, the answer could possibly be that health insurance companies are making it difficult for patients to get reimbursed who undergo these alternatives without their approval first or completely denying them in general.

Schatman noted that Purdue Pharma's commercial campaign from the 90s is a contributing factor to the current opioid crisis we are in today. The company claimed that the risk of addiction from the original formulation of OxyContin was less than 1 percent.

"In 2008 alone, the number of new non-medical users of OxyContin aged 12 years or older was estimated at half a million. This is not to suggest that all non-medical users are addicted or that other opioid analgesics have not been inappropriately promoted, but rather, Purdue Pharma’s biased promotion of OxyContin was certainly the most visible and publicized of such marketing efforts," he concluded.

With the risk of addiction and false marketing practices, chronic pain patients are actively seeking and requesting information from their doctors on other ways to find pain relief.

Some of those alternatives include:

  • Steroid epidural injections
  • Joint injections
  • Fluid injections
  • Physical therapy
  • Nerve blocks
  • Aquatic therapy
  • Massage therapy
  • Chiropractic care
  • Acupuncture
  • Medical marijuana
  • Cannabidiol (CBD) oil

The medical director of a Massachusetts-based pain-management center, Complete Pain Care and the secretary of the Massachusetts Society of Interventional Pain Physicians, Dr. Janet Pearl, revealed, “Every year, pain interventions go to the chopping block, and doctors have to figure out how to provide that treatment and make ends meet."

The problem isn't with doctors not wanting to prescribe anything other than pills per se, but rather the failure of insurance companies to not cover any costs from these therapies, and they aren't cheap.

The Appeal Process

If an insurance company claims, on even mainstream procedures, that it's too experimental, they will not cover any costs associated with that treatment even if it's necessary and even if the patient makes the appointments and goes to the chiropractor because of the medical necessity. The insurance companies make no exceptions. There is an appeal process, but it can be time-consuming with varying degrees of success.

"Imagine doing [an appeal] for almost every patient, especially if you practice in an HMO-heavy area such as California. It is exhaustive," Dr. Shalini Shah, the director of pediatric pain management at the University of California, Irvine Medical Center wrote in an email.

Shah stated physicians appealing insurance denials must fill out endless paperwork, present it to a "peer-to-peer" review board beside the medical director of the specific insurance plan and, in other instances, proffer to a secondary "specialty-specific" review that begins the process over again. This leaves patients relieving their pain through the same old way — high dose opioids.

While some medical reviewers are open to the interests of these patients, a majority of them simply deny everything.

"The policies of insurance companies have forced doctors to increasingly offer pain patients a difficult choice," Shah affirmed.

Basically, we either look to our own wallets and pay for the treatments personally or continue on the opioid pain management path while going through the same back and forth of withdrawing and all of the side effects that come with that. There is a third option: take no action and suffer through the awful pain. But, who wants to do that? Who can afford to do that?

“Even if we want to climb a population out of the well of the opioid epidemic and give alternatives, we can’t," Shah disclosed. "Patients can’t afford the alternatives and insurance companies won’t cover them."

But why?

“Simple. They cost more. It costs more for insurance companies for a physician to do a procedure on a patient or to do physical therapy. It is far cheaper for us to write a prescription for a 30-day supply of morphine. That's the only reason,” Shah reiterated.

Is there a Formula?

According to Clare Krusing, spokeswoman for America's Health Insurance Plans, an insurance trade organization, "Health insurers base their coverage decisions on the available medical evidence around safety and effectiveness. This evidence includes guidelines and recommendations from medical societies as well as peer-reviewed studies in the field. When doctors or hospital systems ask for a treatment to be covered, insurers will have their medical staffs evaluate that procedure based on the evidence.”

The formula seems reasonable, but the real problem is that pain, in general, is objective — you cannot measure someone's pain.

Dr. Houman Danesh, the director of Integrative Pain Management at Mount Sinai Hospital remarked, "Percentage-pain-relief requirements seem arbitrary when patients convey to me major qualitative improvements in their life like being able to sleep through the night, even when the pain-relief level set by the payer isn't reached.”

Looking at epidural injections, most coverage companies have systems in place where a doctor must prove their patient underwent a 50 to 80 percent pain reduction rate in order to get the treatment approved a second time.

“Part of the problem is that in many cases, the pain cannot be completely eliminated, only managed,” spoke the Medical Director of Pain Management at New York-Presbyterian and Weill Cornell Medical College, Dr. Neel Mehta. “Alternative treatments advocated by most pain physicians are not typically 'one-and-done' procedures but instead may need to be done periodically to treat the pain."

Because of this very reason, these companies are in charge in deciding: If my patient has to endure these therapies for multiple sessions, the lowest-cost option would be to stay on opioids.

Opioids predominantly only seem to be cost-effective in the short term.

“That's the fallacy. If you look at the long-term cost of [opioids], plus monitoring, office visits, and drug screenings, it’s cheaper long-term to do the more advanced therapy,” affirmed Dr. Timothy Deer, the co-chair of West Virginia’s Expert Pain Management Panel.

Another problem is the restricted number of superior-quality clinical studies for these alternative treatments. Insurance companies like to see investigations that prove on a large scale that the treatment is effective, safe, and cost-efficient. More times than not, these alternatives cannot be proven because some are relatively new to the market.

In a time where there are more drug overdose deaths than in any other period in U.S. history, something has to give. Opioids are said to have caused more deaths than past heroin epidemics, the previous crack epidemic, and the recent meth epidemic — and it has only increased since 2015. So what are the insurance companies waiting for? The time for change is now.

Updated: February 19, 2020

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