Opioid epidemic: Weighing alternatives for pain management

Providers, payers and consumers will require data to make informed care decisions

There are two sides to the ongoing opioid epidemic. As described by the National Academies of Sciences, Engineering and Medicine, the crisis “lies at the intersection of two public health challenges – reducing burden of suffering from pain and containing the increasing toll of the harms that can arise from the use of opioid medications.”1

This definition encapsulates the dilemma physicians face when determining how to help patients manage pain.

Multifactorial reasons behind the opioid epidemic

When pain became known as “the fifth vital sign” in the early 2000s, physicians increasingly sought to alleviate pain with opioids. At the time, there was low perceived risk of dependence on long-acting prescription opioids. Pharmaceutical companies downplayed the risk of dependence or addiction in sales and marketing activities2. As physicians increased prescribing, especially of synthetic opioids, opioid use disorder (OUD) developed in many patients. In others, left-over prescriptions in the house contributed to OUD in family members. When they could no longer get prescription opioids, some with an OUD turn to inexpensive heroin and fentanyl on the streets.

How courts are reducing impact of the opioid crisis

As a result, North American communities are widely affected by the opioid epidemic. According to the Centers for Disease Control and Prevention (CDC)3, the number of overdose deaths involving opioids was six times higher in 2017 than it was in 1999 and, on average, 130 Americans die every day from an opioid overdose.

CDC chart of Opioid Deaths by Opioid Type in United States

Alternatives to opioid prescriptions

There are, of course, alternatives to prescribing opioids to treat pain, especially chronic pain, which is not an FDA-approved indication for opioids. Examples include non-opioid analgesics, which have been shown to be as effective as opioids4, physical therapy, massage, relaxation, biofeedback, chiropractors and a host of other options.

However, many of these alternatives are more expensive – or perceived as more expensive. There is wide variation among coverage of alternative therapies for pain management, which may be due to the lack of clear best practices, difficulty creating coverage policies for these non-regulated therapies, or economic incentives.5

But in weighing the risks and costs of pain management treatment plans, it is important to understand the burden of opioid misuse and abuse. Opioids may incur lower costs up front, but the long-term costs of treating addiction across a population are high. One study estimates the economic burden of prescription opioid misuse to be $78.5 billion each year, including healthcare, lost productivity, treatment and criminal justice costs.6

In an ideal situation, prescribers would have guidance as to which pain therapies, for which people, would lead to the best outcome. (For some patients, a stable dose of opioids could be the right course of action, and providers should not be penalized for using opioids appropriately.) Payers would understand which providers are achieving better outcomes and could help direct consumers to the right physicians. Consumers would have more access to information about effective alternatives, where appropriate.

This ideal state is not yet reality. But healthcare is making early progress toward helping stakeholders use data to make more informed decisions about pain management.

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References:

  1. ncbi.nlm.nih.gov
  2. Zee AV. The promotion and marketing of OxyContin: commercial triumph, public health tragedy. Am J Public Health 2009;99:221–227.
    www.ncbi.nlm.nih.gov
  3. cdc.gov
  4. doi.org
  5. Heyward, J, Jones CM, Compton WM, et al. Coverage of Nonpharmacologic Treatments for Low Back Pain among US Public and Private Insurers. JAMA Network Open. 2018;1(6):e183044. doi:10.1001/jamanetworkopen.2018.3044 jamanetwork.com
  6. Florence CS, Zhou C, Luo F, Xu L. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Med Care. 2016;54(10):901-906. doi:10.1097/MLR.0000000000000625. ncbi.nlm.nih.gov