Don’t just blame me or the patients for the opioid epidemic
Much attention has been drawn to the opioid epidemic as of late: Obama posed for pictures with music artist and recovered addict Macklemore. The House of Representatives passed a series of (unfunded) legislation to curb the problem. The CDC recently issued new guidelines on opioid use. Questions abound about the role of opioids in the untimely death of Prince. The list goes on.
Lots of solutions are batted around, but one of the biggest problems that is still not adequately discussed is the horrendously distorted reimbursement system for medical care in this country.
First of all, I can prescribe a number of opioid medications without any fight from insurance companies. On the other hand, any time I try to prescribe highly effective adjunct treatments like topical NSAID’s, I am nearly certain to get a prior authorization request from my ole pal the insurance company! Sure, some topical treatments -- like lidocaine -- are of less certain value for pain issues, but isn’t use of chronic opioids just as dubious? I need to be able to easily prescribe effective topical treatments without a fight with insurance or Medicare; then I could prescribe fewer opioids.
The reimbursement system also provides a disincentive for other effective treatments for chronic painful disorders. What if insurance plans actually paid for supervised exercise plans for painful conditions that are known to improve with exercise like osteoarthritis of the hip and knee, peripheral arterial disease, or fibromyalgia? You may argue that most plans pick up the tab for physical therapy (PT), but PT is a short-term fix. I would love to see Medicare and insurance plans subsidize water exercise classes for arthritis patients or an aerobic exercise plan for my fibromyaglia patients.
Finally, there are simply not enough resources in primary care settings to screen for opioid addiction or dependence. I personally believe the most common path to opioid addiction starts with a somewhat legitimate use for opioids in a compliant patient. Unfortunately some of these patients then become dependent or addicted but continue to “fly under the radar” until it’s too late. Sure, many primary care and pain clinics have pain medication agreements, more sophisticated urine drug tests, and other ways to “weed out” those abusing the medications. But it takes a bit of time to actively screen and seek out those with abusive behaviors that are no longer deriving benefit from opioids. Who is funding these aggressive preventive efforts?
As an aside -- and not all related to reimbursement -- I don’t think the FDA is doing us any favors with strengthening warnings about heart attacks and strokes with the use of NSAID’s. I think these warnings have rendered physicians NSAID-a-phobic to an unreasonable degree. I see patients that have been given incredibly lame excuses about why they shouldn’t use NSAID’s.
Sorry, I’ve had a lot of pent-up angst about opioids that I needed to vent!














