Increase Access to Non-Pharma Therapies

 

Introductory Paragraph

There are many benefits of using alternative therapies, also known as Non-Pharmacologic Pain Care (NPPC), and evidence is growing that this is a promising approach in addressing the opioid crisis. There are three avenues for increasing the use of NPCC alternatives. One pathway is for the medical community to promote alternatives that have been verified as effective. The second is for the public to begin to advocate for increased use of NPCC. The third and most powerful leverage point lies with changing the insurance standards that provide reimbursement for NPCC.

Key Information

NPCC health approaches include:

• Acupuncture
• Chiropractic care and spinal manipulation
• Massage Therapy
• Stretching and fitness techniques, such as yoga, Tai Chi, and Qi Gong
• Mindfulness and meditation-based therapies
• Biofeedback
• Transcutaneous electrical nerve stimulation (TENS)

Currently, most insurance plans do not cover most NPPC therapies. Working with insurance companies to cover more alternative and complementary pain therapeutic services can decrease opioid prescriptions for pain. Preventing patients from having opiates introduced into their bodies is one of the most effective ways to reduce the number of people who try an opiate. Using alternate therapies can also prevent unpleasant adverse effects of opiates, such as nausea and vomiting. Often, people using opiates also use marijuana or other illicit substances to treat their nausea, producing a cycle of dependency which makes treatment harder. In today’s society, patients often have complicated medical histories and multiple medications. Considering alternative and complementary therapies can help them avoid adverse drug reactions and preserve their health. For example, this would decrease stress on both the liver which metabolizes the prescription drug and detoxifies the body and the kidney which excretes the drug. NPPC therapies have less toll on the body, can help patients stay healthier, and improve their quality of life.

In contrast to medication-based therapies, many NPPC strategies involve significant patient participation and a commitment to self-care. NPCC strategies tend to increase self-efficacy in managing pain and correlate with improved mood and outcomes in many chronic conditions, including pain. The military has studied “active self-care therapies” as a category of pain management which could be of value in an integrated, multi-modal approach.

Attorneys general (AGs) from 37 states have let the insurance industry know that the fight against the nation's opioid crisis won't be won unless health care providers are encouraged to prioritize non-opioid pain management options rather than opioid prescriptions for the treatment of chronic pain. Professor Dr. Andrew Kolodny at Brandeis University maintains that efforts to limit opioid prescribing in recent years have been positive, but warns that there are still 10 to 12 million patients in the U.S. who have been on painkillers for years and need alternative therapies to offset the potential damage of continued use or unmanaged withdrawal.

Medical Training

The current training system has left primary care practitioners with inadequate tools to deal with some of the most common problems which they will come across. There is limited education time allocated to pain and pain management. Pain curricula in medical school education for MDs in the U.S. ranges from 1-31 hours, with a mean of 11.13 hours. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health professionals who provide care to people with pain. One possible solution is cross-training between fields. Many, if not most, pain clinics are still housed in anesthesiology clinics. Fellowship pain training can now be pursued not only by anesthesiologists but other specialists in neurology, psychiatry, physical medicine and rehabilitation, and internal and family medicine. Physicians who receive fellowship training in pain care learn interventional pain strategies, including NPPC options. The expansion of these strategies within anesthesiology and acute pain practices to chronic pain care have had success in carefully selected patients.

Relevant Research

This paper examines the effectiveness of NPPC therapies. It includes acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, mind-body behavioral interventions, diet, self-efficacy strategies, and meditative movement therapies such as Tai Chi and yoga.

This article is based upon interviews with eight groups of patients, nurses and primary care providers to identify barriers and successes in the use of NPPC treatments in chronic pain.

Impactful Federal, State, and Local Policies

Federal policy has not been developed to coordinate care across disciplines and to increase access to nonpharmacologic care. Improving state and territorial to state and territorial systems could help reduce opioid use. There are a few state Medicaid policy initiatives aimed at increasing access to effective nonpharmacologic therapies as a first-line treatment option for pain conditions. See Promising Practices section below.

Available Tools and Resources

SAFE Project:

• SAFE Veterans provides services to connect veterans, active-duty service members, and their families — all military-connected individuals — to the resources they need to address mental health challenges and substance use disorders.
• SAFE Workplaces provides employers and employees, alike, with the tools and resources necessary to address issues of behavioral health and achieve emotional wellbeing in the workplace.
• See the wiki titled "Expand and Enhance Chronic Pain Prevention and Management" for more detailed information on reducing unnecessary opioid prescriptions and increasing access to alternative/non-opioid pain management methods.

The Joint Commission works with over 20,000 healthcare organizations in more than 70 countries. It has published a 2-page fact sheet titled "Non-pharmacologic and non-opioid solutions for pain management." The Joint Commission has also published "Pain Assessment and Management Standards for Hospitals" which has guidance on leadership, performance improvement, medical staff, and provision of care, treatment, and services.

MyStrength helps fill the gap between generalized pain management and prescription opioid use through education, encouragement, and evidence-based pain management tools. MyStrength, Inc. is a recognized leader and one of the fastest-growing digital behavioral health companies in the US. MyStrength enhances traditional care models while addressing issues of cost, lack of access, and stigma in order to deliver mental health and well-being resources at scale. The platform targets the most prevalent and costly behavioral health conditions, empowering consumers with innovative self-care resources to manage and overcome challenges with depression, anxiety, substance use disorders, and chronic pain. MyStrength collaborates with over 100 health plans, community behavioral health centers, integrated health systems, and accountable care organizations.

Promising Practices

The Oregon Health Plan (OHP) is the state's Medicaid program. It covers acupuncture therapy, chiropractic and osteopathic manipulation, physical therapy, and cognitive behavioral therapy for all back conditions.

Vermont has piloted a program to cover acupuncture therapy for back pain in a Medicaid population and monitor health outcomes and cost-effectiveness.

Minnesota. The Little Falls Program to Reduce Opioid Prescriptions for Pain launched when doctors organized a response to the increasing number of opioid prescriptions and drug-related arrests. They worked with community partners in schools, local health departments, law enforcement, and health alliances to increase addiction treatment options and to monitor prescriptions. They were able to wean 324 patients off opioids entirely and lower prescriptions of opioids from 48,000 a month to 37,000. Patients must sign a contract when they are prescribed opioids that allows for electronic monitoring of their medical records to look for patterns of abuse. Law enforcement alerts doctors if opioids they prescribed are found in possession of someone other than their patient. Rather than punish patients caught selling and abusing opioids, they are given access to Suboxone and to a support team which including a nurse and a mental health specialist. Although the program started off as an abstinence-based program, opioid fatalities led the doctors to changed to a medically-assisted program. This program has gained national attention of national policymakers. Minnesota State Representative Ron Kresha authored a bill designed to help more Minnesota communities develop opioid abuse prevention programs based on the program in Little FallsThe aim is to establish and fund opioid abuse prevention pilot projects throughout the state. Each pilot project has a multidisciplinary controlled substance care team to:

• deliver health care services and care coordination to reduce inappropriate use of opioids
• address any unmet social service needs that create barriers to managing pain effectively and obtain optimal health outcomes
• provide prescriber and dispenser education
• promote best practices related to opioid disposal
• engage community partners outside the health care system in such efforts.