Supporting Alternatives to Opioids

The Centers for Disease Control and Prevention (CDC) is the leading national public health institute of the United States.  Its main goal is to protect public health and safety through the control and prevention of disease, injury, and disability in the US and internationally. The CDC focuses national attention on developing and applying disease control and prevention.  When the CDC steps in, as it has recently with regard to our nation’s opioid epidemic, everyone pays attention.

In March of 2016 the CDC published new treatment guidelines regarding how chronic pain patients should be treated in response to the opioid crisis that has resulted alarmingly high death rates in our country. (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm)

These guidelines specifically identify the importance of providing “non-pharmacological treatment” options to chronic pain patients and those at risk of opioid dependency and addiction. “Non-phamacological treatment”, according to these guidelines, includes physical therapy, spinal manipulation, acupuncture, massage therapy and cognitive behavior therapy in particular.

Not only does the CDC emphasize the importance of “non-pharmacological care” in treating chronic pain, but it also identifies reimbursement policies that create barriers to access to these provider types, thus contributing to the opioid addiction problem!  The guidelines state: “CDC will work with federal partners and payers to evaluate strategies such as payment reform and health care delivery models that could improve patient health and safety. For example, strategies might include strengthened coverage for non-pharmacologic treatments, …..”. This is clear recognition by the CDC of health care recipients' reimbursement issues that need to be addressed to improve access to “non-pharmacological treatment” i.e. chiropractoric.

US Food and Drug Administration (FDA) Recommends “Chiropracty” in the Battle Against Opioids!

The Centers for Disease Control’s new guidelines for chronic pain management not only include spinal manipulation as a primary form of recommended care, but also identify problems with insurance reimbursement that create barriers to patients with chronic pain who seek non-pharmacological treatment such as chiropractic care. It is significant to note that, in so stating, the CDC has identified these insurance reimbursement barriers as factors that contribute to the opioid epidemic.

Subsequent to the release of the CDC chronic pain guidelines last year several other major entities in the world of healthcare jumped onto the bandwagon, issuing their own treatment guidelines for chronic pain and opioid management. 

The list includes the American College of Physicians, the Veteran’s Administration, the Federation of State Medical Boards, and in May of 2017 even the Food and Drug Administration released recommendations for treating chronic pain and opioid management.  

Each and every one of these guidelines recommended “non-pharmacologic therapies” (including spinal manipulation) as a first line of treatment for chronic pain patients, especially those at risk for opioid addiction.  

Who would have imagined that the Food and Drug Administration would one day endorse chiropractic care as a recommended treatment for any problem?! (FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain.)

In today’s world of “evidence-based healthcare” the many years of hard work by the chiropractic research community, often under-funded and over-worked, has paid off as the crisis created by the tragic opioid epidemic has gained the spotlight of our nation’s focus. It is because of these labors that when the nation turns to the hard evidence of effective clinical outcomes, chiropractic care stands on its own merits.

Joint Commission Adds Teeth to Use of Chiropractors in the Battle Against Opioids

There is exciting news about the inclusion of “non-pharmacological therapies”, including chiropractic, in the newly published treatment guidelines for chronic pain and opioid management.  The recognition of chiropractors as meaningful participants in the battle against opioid addiction and death is truly gratifying.  

Anyone who has been participating in healthcare for very long knows that there is a big difference between a “guideline” and a “standard of care”.  Guidelines are recommendations and as such are not really enforceable in any substantial way.  Compliance with treatment guidelines is voluntary, and in many cases well-conceived and well-intended guidelines are not embraced because so few providers elect to follow them. Sometimes, especially when changes in provider behavior are involved, external motivation has to be entered into the picture in order to bring about the “voluntary adoption” of guideline recommendations.

One organization that “brings some teeth” to guidelines compliance is the Joint Commission of Healthcare Organizations (JCAHO).   The Joint Commission is a nonprofit organization that accredits more than 21,000 US health care organizations and programs. A majority of US state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements.  

In July of 2017 the Joint Commission issued a revised compliance standard that mandates that any hospital seeking accreditation from JCAHO must “provide nonpharmcologic pain treatment modalities” for the treatment and management of chronic pain (Standard LD.04.03.13, effective January 1, 2018). Like the treatment guidelines that we have mentioned in previous articles, this new requirement is an effort to embrace the current (and worsening) opioid epidemic facing our country at this time.

As our healthcare system embraces these new guidelines and compliance standards Doctors of Chiropractic are afforded an expanded opportunity to alleviate pain, suffering, addiction and death due to chronic pain and opioid abuse.

Are Insurance Companies Contributing to the Opioid Crisis With Their Reimbursement Policies? -- Ask the National Association of Attorneys General!

The National Association of Attorneys General (NAAG) is an organization of 56 state and territorial attorneys general in the United States. The members include the Attorneys General of all 50 states and the equivalent chief legal officers of the District of Columbia and other US territories.

Last September the attorneys general of 37 states (including Arizona Attorney General Mark Brnovich) signed a letter to America’s Health Insurance Plans (AHIP), a national political advocacy and trade association with about member 1,300 insurance companies who provide health insurance coverage to more than 200 million Americans. The content of this letter is of interest to all Doctors of Chiropractic.

In part, this letter states that the “undersigned State Attorneys General” urge the members of the AHIP “to take proactive steps to encourage your members to review their payment and coverage policies and revise them, as necessary and appropriate, to encourage healthcare providers to prioritize non-opioid pain management options over opioid prescriptions for the treatment of chronic, non-cancer pain”. (emphasis added)  And in the same opening paragraph the letter states: “As the chief legal officers of our States, we are committed to using all tools at our disposal to combat this epidemic and to protect patients suffering from chronic pain or addiction, who are among the most vulnerable consumers in our society.” (http://www.naag.org/assets/redesign/files/sign-on-letter/Final%20NAAG%20Opioid%20Letter%20to%20AHIP.pdf)

This letter goes on to describe in specific detail how the reimbursement systems used by insurance companies incentivize ineffective prescription of opioid medication for chronic pain management. In the final paragraph of this letter the Attorneys General clearly place the insurers on notice  by stating: “We are thus committed to utilizing all the powers available to our individual offices to ameliorate the problems caused by the over-prescription of opioids and practices and to promote policies and practices that result in reasonable, sustainable, and patient-focused pain management therapies. In the near future, working in conjunction with other institutional stakeholders (such as State Insurance Commissioners), we hope to initiate a dialogue concerning your members’ incentive structures in an effort to identify those practices that are conducive to these efforts and those that are not. We hope that this process will highlight problematic policies and spur increased use of non-opioid pain management techniques.” (Emphasis again added.) “The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable.” 

In their new Guidelines for Opioid Rx and Chronic Pain, the Centers for Disease Control: “Identifies barriers to non-pharmacological providers in terms of insufficient and punitive insurance coverage and policies” and recommends “strategies to consider to enhance implementation of the recommended practices. CDC will work with federal partners and payers to evaluate strategies such as payment reform and health care delivery models that could improve patient health and safety. For example, strategies might include strengthened coverage for non-pharmacologic treatments…”

Source material provided in February 2018 by The Arizona Association of Chiropractic