As parts of America struggle with widespread opioid addiction, communities are trying various techniques to attempt to bring rates down. One important step is to make sure that people who have chronic pain have access to non-opioid pain treatments that work for them. Reducing the number of people with chronic pain who get higher doses of opioids, or any opioids at all, might directly prevent some folks from developing addictions to their prescriptions. It could also help cut down on the number of pill bottles that are out in the community—in nightstands and bathroom cabinets, where people without prescriptions might get their hands on them.
So a new study tried to find out: Do Americans have access to proven, non-opioid treatment for chronic low back pain? That is, do their insurance plans cover them? Nearly all the plans the researchers analyzed do indeed cover physical and occupational therapy, at a median cost of $30 to $40 per visit, the study found. Many plans also covered chiropractor appointments ($20 to $60 each). However, few plans explicitly said they covered psychological treatments, which might include learning psychological techniques for dealing with chronic pain, and which a 2014 review found are helpful to people with the most difficult-to-treat pain.
To Caleb Alexander, the study's lead scientist, that's worrisome. "Clinicians and patients need to have choices," says Alexander, who co-directs the Center for Drug Safety and Effectiveness at Johns Hopkins University. Doctors and patients have plenty of choices when it comes to opioid drugs. In a study published in June, Alexander and his team found that Medicare Advantage insurance plans typically cover 17 different opioid drugs for the treatment of low back pain, while private insurance plans typically cover 23 opioids. In light of that data, the more restrictive insurance plans are about the non-opioid treatments they'll cover, Alexander says, "the more that doctors and patients are going to turn to prescription drugs."
"There's already such a tendency to use pharmacologic treatments over non-pharmacologic treatments. A pill for every ill," he says. "The last thing we need is coverage policies that further promote this tendency."
For the study published Friday, in the journal JAMA Open, a team of researchers from Johns Hopkins and federal agencies analyzed the policy documents of 15 Medicaid plans, 15 Medicare Advantage plans, and 15 commercial insurance plans, offered across 16 states. They also interviewed dozens of medical officers in charge of these policies, who noted they've recently been trying to expand coverage of non-opioid pain treatments. Still, they said they had trouble integrating opioid and non-opioid therapies—making sure, for example, that new pain patients tried physical or psychological therapy before moving onto opioids, as needed. That's the progression that the Centers for Disease Control and Prevention recommend, to minimize the risks of addiction and overdose that come with opioids. Only one large Medicaid plan, in a state hard hit by opioid deaths, had fully integrated its opioid and non-opioid back pain strategy.
This is clearly a new frontier for insurers, Alexander says. The plans his team examined varied wildly in their policies: how long they would cover physical therapy sessions for, who could prescribe non-opioid therapies (a primary doctor? a specialist?), what even exactly they covered. These big differences in plans suggest that insurers haven't figured out yet what the ideal plan is for low back pain, Alexander says. Whatever it is, it can't rely solely on opioids, he argues. "There are dozens of drug and non-drug treatments for chronic pain and for far too long, we've acted as if opioids are the only tool in the toolbox," he says. "Insurers have a very important opportunity to positively impact the opioid epidemic. They can either be a part of the problem, or a part of the solution."