It’s an unmitigated disaster. One hundred million pain patients. Millions addicted to opioids, hundreds of thousands dead. Pain patients abruptly cut off medication they’ve depended on, sometimes for decades, and offered nothing to replace it. Doctors, fearful of prosecution for overprescribing, dropping pain patients like hot potatoes. Pain patients unable to find any doctor that will treat them. Patients turning to heroin when they can’t get their prescription painkillers. Articles in prestigious medical journals suggesting that doctors stop asking patients about pain or offer them placebos. Reported suicides by pain patients who found life intolerable without their meds and threats by pain patients of more suicides.
How did we get to this terrible place? And how do we get out of it?
In the good old days, medical treatment was between a patient and their doctor. Doctors spent time with patients figuring out what was wrong and how to fix it. No one told doctors how long to spend with their patients. They billed for their time accordingly. When health insurance first came along, it was nonprofit. Medically necessary meant a doctor prescribed it and it was for a medical purpose.
There were no limits on physical therapy, as long as a doctor prescribed it. If psychotherapy or chiropractic were covered services, you could go for as long or as often as you and your health care provider thought it was necessary. Interdisciplinary pain clinics, more than a thousand of them, were springing up all over the country, many of them connected with the most prestigious medical institutions. In these clinics, physicians, physical therapists, psychologists and biofeedback practitioners would all evaluate each patient and together come up with a plan to address each patient’s pain. Research showed this interdisciplinary approach was the most effective treatment for chronic pain.
Then along came managed care, starting in the late 1970s. Within a couple of decades, it became the predominant insurance model. While managed care’s stated purpose was to control rising health care costs while optimizing care, its real purpose was to wring as much profit for insurers out of premiums paid as possible. Health care providers were forced to join insurance networks if they wanted their services to patients to be reimbursed. Fees were slashed. Doctors were paid more per minute for shorter visits than they were for spending more time with patients.
Often if they spent longer with patients despite the disincentives to do so, their office visits would be “downcoded”: Insurance companies would deny payment for the longer visit, claiming that it was not medically necessary. Many medical procedures were denied, forcing doctors to spend long hours on the phone with insurance companies appealing denials of care. In self-defense, many physicians joined large medical groups that pooled their resources to hire people to deal with the insurance companies. Then practice managers started telling doctors how long they could spend with patients in order to maximize income for the group.
As difficult as life became for physicians, it became much worse for non-physician health care providers. Psychotherapists, physical therapists, occupational therapists, and chiropractors were all subjected to annual visit limitations, pre-treatment authorization requirements and medical necessity reviews. Visits to these providers were generally limited by insurance contracts to 20 per year, while medical necessity reviews often reduced available visits to a fraction of that number. These health care providers started having to spend an extraordinary amount of their time filling out paperwork and appealing treatment denials. To make matters worse, since the implementation of managed care, fees for chiropractors, physical therapists, and psychotherapists have not increased. After accounting for inflation, the freeze on fees amounts to a pay cut of over 65 percent. This has significantly affected the availability of care.
Purdue Pharma started promoting their new extended release opioid Oxycontin in 1996. Prior to that time, physicians did not prescribe opioids, also known as narcotics, for chronic pain because narcotics were known to be highly addictive. But Purdue assured physicians and insurers that they didn’t need to worry: the rate of addiction to Oxycontin was miniscule because of its time release properties, and they could safely prescribe it to chronic pain patients. Insurers decided this was a cheap way to treat chronic pain, and they stopped paying for interdisciplinary pain clinics. Over 90 percent of these clinics closed down over the next few years. Insurers also increased their restrictions on chiropractic and physical therapy. Prescriptions for opioids of all kinds soared in the next 20 years, as did rates of addiction and overdose.
In order to at least look like they were doing something about the addiction problem, federal officials went after doctors, prosecuting not only those running “pill mills” where doctors sold pills directly to drug seekers without medical justification, but also doctors prescribing according to generally accepted medical standards to pain patients. Many doctors lost their licenses, and some went to jail. The rest became frightened about the risks of using the only tool they knew how to use that was available to treat pain.
In recent years, evidence has been building that acupuncture, massage, nutrition, herbs, exercise, marijuana, and low-level laser therapy are effective treatments for chronic pain. Evidence for the effectiveness of physical therapy, psychotherapy and chiropractic has also increased. But most physicians and insurers have been blind to this evidence. In the United States, pain treatment equals opioids.
In 1996, when Purdue began their deceptive promotional campaign for Oxycontin (they were fined in 2007 for consumer fraud for lying about Oxycontin’s risks of addiction), they cited the following statistics: 34 million Americans were in chronic pain, medical costs were $100 billion and lost productivity due to chronic pain was costing the economy $60 billion. Fifteen years later, In 2011, the Institute of Medicine reported the following statistics: 100 million Americans in chronic pain, medical costs of about $300 billion and about $300 billion in lost productivity. Sounds like a failed medical policy to me.
What we need to do now is to give doctors the time and resources they need to help their pain patients. Doctors need to be educated about non-pharmaceutical ways to treat pain and insurers need to be required to adequately cover all proven treatments for pain. Patients need to be given access to all treatments that can help relieve their suffering, especially those that are less risky than opioids. No patient who depends on opioids for pain relief should be denied opioids without evidence of addiction unless and until they have been given other treatments to replace their medication that work at least as well. We also need to stop criminalizing doctors who are just trying to help their patients.
Cindy Perlin is a social worker and author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free.
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