3.2 Pain Management

Improved HU access relates to other recommendations in this report, including: 1. Co-Management of Care Between Primary Care Physicians and Hematologists. Frequent monitoring and visiting a hematologist are all associated with improved HU uptake and adherence.232 2. Telehealth. Telehealth can be helpful for monitoring HU use among rural populations.233 3. The Transition from Pediatric to Adult Care. Strategies that improve transition from pediatric to adult care are expected to improve HU adherence.234 4. NC Sickle Cell Syndrome Program Educators. In North Carolina, SCD clinicians suggested having state educators contact patients to explain the benefits of HU and encourage them to continue using the medication.

Additional Considerations

PHPs can cover telehealth and other remote services—whether performed by providers or CHWs—to remind patients with SCD to adhere to an HU regimen. PHPs should ensure that patients with SCD are being prescribed and adhering to HU as recommended, and that both providers and patients are aware of HU’s efficacy and safety. For both children and adults, PHPs can do this by facilitating coordination between primary care physicians and hematologists, and NC DHB can reimburse such coordination activity. For pediatric patients transitioning to adulthood, the recommendations outlined in Part II section 1a should increase HU adherence by increasing patient interactions with adult providers. Adjustment of PHP contracts to reimburse pain management would be a shortterm investment because contracts can be changed unilaterally.

NC Medicaid should require PHPs to take steps to improve pain management approaches within the SCD population.

Implementation: • NC Medicaid should require PHPs to offer a variety of opioid and non-opioid pain management techniques. • NC Medicaid should encourage destigmatization of opioid use amongst this patient population. • NC Medicaid should reimburse individualized pain management planning.

Background

Pain is the most common SCD morbidity and the leading cause of SCD-related hospitalization.235 Opioids are a mainstay of SCD pain management, but in light of dependency concerns, people living with SCD have difficulty accessing opioids for pain management.236 A significant reason for this difficulty is opioid stigma among providers and suspicions that patients are abusing opioids. Integrative, non-opioid therapies such as cognitive behavioral therapy, yoga, acupuncture and dietary supplements have also demonstrated effectiveness in reducing pain severity in patients with SCD. These therapies can help reduce patient dependence on opioids, which can have harmful long-term effects.237

North Carolina Context

In addition to opioid stigma, a North Carolina SCD clinician noted that provider oversight may also be undermining SCD pain management. Clinicians prescribing opioids for patients with chronic pain fear scrutiny from state medical boards and federal regulators.238 NC Medicaid does not require prior authorization for some short-acting opioids used for SCD pain management for up to five days, but it does require prior authorization for longer use.239 Patients with SCD often remain hospitalized for

six to ten days. As a result, they are often likely to need prior authorization to address their VOCs, or pain crises.240 By contrast, no prior authorization is required for opioids used to manage pain associated with cancer.241 NC Medicaid already covers behavioral health interventions, chiropractic services, and acupuncture, all of which could be useful for SCD pain management.242 However, NC Medicaid does not cover many non-opioid therapies.243 Moreover, providers in North Carolina indicate that NC Medicaid does not sufficiently reimburse work with patients on pain management.

Evidence

ASH recommends that pain management be individualized to maximize benefits to the patient and to minimize risk of hospitalization.244 Individualization of pain management plans also mitigates bias- and stigma-associated withholding of appropriate pain care. Without Medicaid coverage for more nonopioid therapies and reimbursement for pain management, providers are unable to optimally manage pain for their patients, increasing their risk of pain crises and hospitalization.

Other states have provided coverage for an array of non-opioid pain management techniques that have resulted in significant health improvements and cost reductions. Florida’s Medicaid program, offering acupuncture, chiropractic services, and massage therapy for eligible individuals with chronic pain, resulted in improvements in cognitive and physical function a nine percent reduction in per member per month costs.245 Likewise, Vermont Medicaid enrollees saw decreases in opioid use as a result of acupuncture therapy.246 Access to both opioid and non-opioid therapies is essential to successfully managing pain and reducing costly utilization.247 Federal guidelines recommend excluding patients with SCD from restrictions on opioid access.248 Providers in eastern North Carolina report giving their patients pain management plans which they can present when they see other providers (e.g., in an ED or primary care setting). They believe that this helps non-SCD providers deliver more effective care consistent with the patient’s needs.

Additional Considerations

Reimbursement for pain management, exemptions from opioid oversight regulation, and provider education to identify the role of bias and stigma in limiting access to pain treatment would enable providers to individualize treatment for patients, better address pain and reduce SCDrelated hospitalization costs.249

Adjustment of PHP contracts to reimburse pain management would be a short-term investment because contracts can be changed unilaterally by including them in PHP value added services/ in lieu of services. Determination of non-opioid therapies to cover would be a medium-term investment because it would take time to develop. For example, some non-opioid pain management techniques, including yoga, virtual reality, and guided relaxation, are not wellstudied.250 NC Medicaid should seek additional information to ensure that the pain-reducing benefits of covering any particular technique justify the costs. In the long term, NC Medicaid should work with state regulators to exempt SCD clinicians from opioid audits while still ensuring that they do not over-prescribe opioids. NC Medicaid should also work with PHPs to engage providers in bias training, opioid education, and opioid destigmatization efforts.