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Specialty Pharmacy Continuum • May/June 2020
OPERATIONS & MANAGEMENT
The Time Is Now for Nonopioid Pain Modalities Alexandria, Va.—Our health care system needs to look beyond prescribing opioid medications for pain to consider a range of modalities based on patient preferences, speakers said at the 2020 Opioid Management Summit. “We’re not saying you can’t take opioids,” said Cheri Lattimer, RN, BSN, the executive director of the National Transitions of Care Coalition, a nonprofit organization dedicated to raising awareness about transitions of care among health care professionals. “When you have a catastrophic injury or cancer, where pain has to be controlled by medications, we don’t want to take that away. But how can we give more options to individuals, whether the patient is an adolescent with a sports injury, a veteran or a senior?” On average, 130 Americans die every day from an opioid overdose, Ms. Lattimer said, citing CDC statistics (bit.ly/39G5YxW). This includes both prescription opioids and illicit drugs, she said. Part of the problem stems from a lack of education, and U.S. patients believing they should not have any pain. The fastest-growing population taking opioids is adults aged 65 years and older, Ms. Lattimer added, and most seniors are largely unaware of their options for pain management beyond what their doctors suggest. Providers need to alter their management of pain to factor in patient preferences, social determinants of health, behavioral health and additional modalities, she said. Complicating the issue, nonopioid therapy options may be outside bundled payments, resulting in higher patient copays—or not covered at all. CDC guidelines and the National Pain Strategy are very open to nonpharmacologic care to help address the overuse of opioids, said chiropractor Sherry McAllister, MS (Ed), DC, the executive vice president of the Foundation for Chiropractic Progress. Complementary pain therapies include spinal manipulations by chiropractors, yoga, massage, acupuncture and physical therapy. “The Joint Commission, American Pain Society and American College of Physicians all want us to go with nonpharmacological options of pain control if possible, and to have discussions with patients,” Dr. McAllister said. Emerging research is demonstrating the benefits of some of these therapies in pain management, she said, including a three-part series published in the Lancet (www.thelancet.com/series/low-backpain), suggesting spinal manipulation
as a recommended approach to manage low back pain (2018;391[10137].doi. org/10.1016/S0140-6736(18)30725-6). Another paper in JAMA Network Open (2018;1[1]:e180105) demonstrated that chiropractic care, when added to usual medical care, resulted in moderate short-
modalities such as virtual physical therapy. The goal would be to determine whether such treatments could help improve patient outcomes and result in less opioid use among those enrolled. The specifics are still being discussed, Dr. Sherman said, but could be particularly helpful during the COVID-19 pandemic with people staying home. The insurer also is looking into exercises to promote mindfulness to improve how people cope with pain, conducting trainings for some members and employees, and making lessons
130 Americans die every day from an opioid overdose.
Payors and providers are encouraging the use of a variety of nonopioid pain treatments, including physical and occupational therapy, electrical stimulation, chiropractic manipulations and phonopherosis, which uses electrical currents to deliver topical medication through the skin.
term improvements in low back pain intensity and disability among active duty military personnel. Specifically, adjusted mean differences in scores at week 6 were statistically significant in favor of usual medical care plus chiropractic care compared with usual medical care alone for low back pain intensity (mean difference, –1.1; 95% CI, –1.4 to –0.7), disability (mean difference, –2.2; 95% CI, –3.1 to –1.2), and satisfaction (mean difference, 2.5; 95% CI, 2.1-2.8). Health plans are becoming increasingly interested in alternative pain paths, commented Michael Sherman, MD, MBA, the senior vice president and chief medical officer for Harvard Pilgrim Health Care in New England. “We’re very interested in some of the newer modalities of treating pain, specifically [modalities] that are nonopioid,” he said. For example, his company is exploring the launch of a trial of a mobile app that would educate patients about nonopioid
available virtually. It is also studying a biofeedback device that may help people alter how they respond to pain. “There is very much a willingness to look at these kinds of new approaches,” Dr. Sherman said.
Plan Covers Wide Range Of Alternative Therapies Highmark Health, an integrated delivery network in the Pittsburgh area, covers a range of modalities for pain management among its different plans, said Caesar DeLeo, MD, the company’s executive medical director and vice president of strategic initiatives. These include physical and occupational therapy, electrical stimulation and transcutaneous electrical nerve stimulation therapy, chiropractic manipulations, and phonophoresis, which uses electrical currents to deliver topical medication through the skin. Some plans cover acupuncture or
offer a discount to a network of providers offering acupuncture, tai chi, massage and other alternative therapies, or cover trigger point injections to treat painful areas of muscle, Dr. DeLeo said in a phone interview. In addition, the network includes pain management centers of excellence where some members are referred for nerve blocks, behavioral therapy and other treatments. In other tactics, the company has promoted CDC guidelines for safe prescribing of opioids, set prior authorization limits for initial duration of opioid prescriptions, and encouraged parents to talk to oral surgeons before their children are prescribed opioids for wisdom tooth extraction, he said. —Karen Blum The sources reported no relevant financial relationships.
