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Monday May 02, 2016

Insurance Hurdles Add Challenge to Treating Pain

If you are an opiate prescriber or are dependent on opiate prescriptions, you are likely well aware of the CDC's new guideline for prescribing opioids for chronic pain(www.cdc.gov).

At some point in your life, the quality of the pain management you deliver or receive is likely to be impacted by how the medical community responds to these guidelines. They likely also will impact insurance coverage of certain medications and will undoubtedly influence further regulations.

You could say that the time had come, and perhaps was even overdue, for CDC's guidelines, and I am cautiously optimistic about what their ultimate effect will be. I have been painfully aware of the need for more guidance and oversight of pain management in the primary care setting, especially as new abuse-deterrent medications become available. I was hoping for some sort of clear pain management algorithm that would pressure insurance companies to provide blanket coverage for physical therapy and abuse-deterrent medications, while withdrawing support for the use of the frequently abused prescription narcotics.

It took me a couple of reads through the guidelines and a few reviews of the commentary from my peers before I began to see that this might be exactly the impetus we need.

I think the solutions to the opioid issue lie not in the guidelines themselves but in the larger conversation they generate and the medical community's response as a whole. To that end, let me present a glimpse into the difficult reality I and many other physicians face on a day-to-day basis. I am continuously confronted with the challenge of treating the subjective complaint of pain, sometimes called the fifth vital sign, while maintaining safe medical practice and achieving the often coveted, and now mandated, secondary goal of patient satisfaction.

One thing is clear; patients rarely come to the clinic or the ER complaining of pain with the expectation that they are going to get a sticky note saying, "Go pick up some Tylenol or Motrin at your local convenience store."

When you start with this understanding and the premise that you are a medical service provider who is being rated on the quality of your service, things get really tricky. For example, what do you do when the patient who you already have seen five times for back pain says, "Doc, I've done all the exercises and tried all the medications you prescribed me, but none of it is working?"At that moment, you review the chart and see that, indeed, patient X has failed every nonsteroidal anti-inflammatory drug (NSAID) known to man and jumped (or limped) through all the hoops you set. Or you look at the allergy list and you see "NSAIDS, acetaminophen, codeine and tramadol" while your patient looks you square in the eye and says, "That's right, Doc, the only pain medications I can take are hydros or oxys, and if I'm going to be honest with you, Percocet works the best for me."

Then there is the fibromyalgia patient who has failed pregabalin (marketed as Lyrica), and the insurance won't pay for milnacipran (Savella) or duloxetine (Cymbalta), which leaves the higher risk medication amitriptyline (Elavil).

How about the osteoarthritis patient who can't afford celecoxib (Celebrex)? You write a script for the diclofenac patch (Flector), but it is only covered for acute arthritis pain and is not affordable with Medicaid or Medicare.

For your lumbar radiculopathy and sciatica patient, you think, "Wouldn't it be great if I could write a script for a lidocaine patch (Lidoderm)?" But you know you can't because it is only covered for post-herpetic neuralgia. But no worries because of course there is gabapentin (Neurontin, Gralise and Horizant) which is really only indicated for restless leg syndrome, partial seizures and post-herpetic neuralgia, but thankfully is covered by all insurances.

If you are really trying to reduce the number of prescription narcotic pills floating around your neighborhood, you might get inspired when a pharm rep stops by to talk to you about the new options in abuse-deterrent pain management. So in your patient encounters, you start talking up abuse-deterrent variations of buprenorphine (Butrans and Belbuca), hydrocodone (Hysingla and Zohydro), morphine (e.g. Embeda), and oxycodone (Xtampza), but later you find out that these drugs are unaffordable, require a step edit, or need a prior authorization that says something like, "patient must first fail Opana, MS Contin, or Nucynta."

You likely have similar stories of your own. My point is that we, as medical professionals, are all deeply invested in the welfare and satisfaction of our patients. We are also adaptable and extremely adept at achieving good outcomes using whatever tools we have.

So, speaking for myself, I can say that I am longing for the day when insurance companies no longer dictate how I practice, and I am looking forward with tempered expectations to see if the CDC's opioid prescribing guidelines will lead to real solutions. Whatever the outcome, I am certain that I and many physicians like me will keep plugging along, doing the best job we can for our patients within the parameters that are set for us.

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.

Posted at 04:03PM May 02, 2016 by Kurt Bravata, M.D.

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