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LMS President’s Message, May 2018

LMS President’s Message,
May 2018
by Tuyen T. Tran, MD, MBA

Figure 1. 3 Waves of the Rise in Opioid Overdose DeathsPer CDC statistics, from 1999-2016, more than 350,000 people died from an opioid overdose. In 2016, over 42,000 Americans died of opioid overdoses.  Most of our efforts to combat the opioid epidemic revolves around 1) mandating education on opioid prescribing, 2) integrating prescription drug monitoring programs, 3) improving data collection and sharing, 4) treating opioid overdose (Naloxone), and 5) increasing availability of opioid use disorder treatment.  Although we have made strides in combating the opioid epidemic, there is much more work ahead of us.  (See Figure 1.)

Figure 1. 3 Waves of the Rise in Opioid Overdose Deaths

Prescription monitoring programs and widespread education on proper opioid prescribing has tremendously reduced the availability of prescription opioids. The naloxone campaign and avoidance of concomitant prescribing of benzodiazepines and opioids have reduced the unnecessary deaths related to opioid overdoses.  However, the treatment of those already afflicted with addiction has been sluggish.  Blue Cross Blue Shield Association reported recently that their members with an opioid use disorder spiked 493% but members who received treatment (Medication Assisted Treatment) rose only 65%.1 More discouraging, we are forgetting to address the underlying problem which led many of these people to addiction – chronic pain.

American Medical Association (AMA) and American Society of Addiction Medicine (ASAM) have partnered to develop a new payment model for the treatment of addiction. The alternative payment model (APM) called Patient-Centered Opioid Addiction Treatment (P-COAT) will provide appropriate financial support and encourage the multi-disciplinary coordination of medical, psychological, and social support to successfully treat opioid addiction.  Hopefully, this will enhance patients’ access to quality, evidence-based treatment.

“What about my chronic pain, doctor?” Opioid analgesics are clearly not the solution.  But, should we as physicians not alleviate some of our patients’ pain and suffering?  According to the CDC, there are many non-opioid alternatives (joint injections, steroid injections, physical therapy, fluid injections, nerve blocks, radiofrequency ablation); but, how many of these approaches are covered by insurance?  Or why are the Prior Authorization barriers so restrictive that the service is essentially not covered?

The opioid epidemic has unnecessarily taken many lives. The cost of untreated addiction to society and healthcare is tremendous.  Ineffectively treated patients frequent the Emergency Department or hospital due to complications related to drug use.  And studies show that these patients often require repeated visits to the Emergency Department or are readmitted to the hospital.  Patients who do not receive treatment either do not show for work or have lower productivity.  These patients are often involved in crimes, increasing the cost of the criminal justice system.  And in addition to these financial costs, how do we measure the havoc addiction causes in families and relationships?  The National Institute on Drug Abuse reported in January of 2018, for every dollar invested in addiction treatment, the return yield is between $4-7 in reduced drug-related crime, criminal justice costs, and theft.  If healthcare savings are included, the return yield exceeds $12 for every dollar invested.

So why are we not aggressively advocating evidence-based treatment (MAT) of opioid addiction? Why are we not pushing for more non-opioid treatment modalities to alleviate our patients’ pain and suffering?

 

References

  1. America’s Opioid Epidemic and Its Effect on The Nation’s Commercially-Insured Population. Retrieved from Blue Cross Blue Shield Association, 2017: https://www.bcbs.com/the-health-of-america/reports/americas-opioidepidemic-and-its-effect-on-the-nations-commercially-insured
  2. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2017. Available at http://wonder.cdc.gov.
  3. Kolodny et al. 2015. The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, 559-74
  4. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths – United States, 2000-2014. MMWR 2016, 64(50); 1378-82.