Big problems are rarely solved with simple solutions. The opioid crisis is an example. This is an important opportunity to make changes that can save and change tens of thousands of lives — and we already know what needs to be done and how to do it.
In today’s society, where we see problems fixed by the end of a 30-minute sitcom, we are sometimes lulled into believing that issues in our own lives similarly can be fixed by a quick pill or the stroke of a pen. However, as we all know too well, health care issues tend to be complicated and involve many stakeholders. The opioid epidemic is no exception, juggling the interests of insurance companies, governments, medical providers, social workers, therapists, pharmacies, facilities and the patients themselves. All of this is done in the backdrop of other limitations, including geography, time, economics and societal stigmas.
The first reaction of many states to the opioid crisis was to limit the number of pills given to patients who have never received opioids. Studies have shown that patients who receive more than a 30-day supply of opioids, as compared to their counterparts receiving just seven days of opioids, on the first prescription have a dramatic increase in risk of continuing opioid use at one year and three years after the initial prescription. Many patients only use five or seven days of their initial prescription and then save the rest of the pills, which are frequently stolen or diverted for other uses.
By limiting the supply, we can decrease the number of diverted medications and — hopefully — ultimately decrease the number of patients with opioid use disorder. Unfortunately, patients typically still pay the same amount for seven-day prescriptions, through insurance plans, that they pay for 30-day prescriptions, leading to frustration and increased costs related to multiple refills required if a month of medications is ultimately needed. In other words, under new legislation, an opioid-naive patient may pay four copays for a 30-day prescription instead of the typical one copay for those who have taken opioids in the past.
Even as we reduce the supply of opioids, those who are at risk or are dependent on opioids have difficulty obtaining access to providers. Fewer than 2,000 providers have become board-certified in addiction medicine under the recognized American Board of Preventive Medicine. Medication-assisted treatment (MAT), touted by many as the best option today, requires an “X waiver,” which was part of the Drug Addiction Treatment Act (DATA) of 2000. After 20 years, only about 5 percent of U.S. medical doctors have obtained the appropriate waiver to prescribe medications such as Suboxone (buprenorphine) for treatment of opioid dependency. Of the 82,000 physicians, only a small fraction actually prescribe MAT for patients on a regular basis. Given the low participation, many medical societies now support deregulation of MAT.
Finally, recent studies have shown that facility-based treatment centers, such as inpatient rehabilitation centers, are significantly more likely to be out-of-network than other medical providers. This leads to overall increased cost to the system and the patient.
Despite these barriers, some patients still elect to pursue treatment. When they arrive, a myriad of “cost-containment” measures block access — copays, deductibles, coinsurance. While cost-sharing is important to ensure that patients think about the care they receive, it can discourage patients from seeking or continuing care. Statistics reveal that only 10 percent of patients who need treatment for substance use disorder actually seek that treatment. When these patients finally decide to pursue treatment, cost barriers can further erode the number of patients who complete treatment. Failure to pursue and complete treatment can lead to additional costs — in excess of $20,000 per year, per patient, according to a recent Milliman study.
If we want to win the war against the ongoing opioid pandemic, we will need everyone to participate. Physicians need to be comfortable referring patients who use opioids for longer than necessary or at higher doses than expected. Surgeons need to be incentivized through value-based reimbursement to refer patients for evaluation of issues known to lead to worse outcomes and prolonged usage. The government and insurance companies need to support bundling, improve access, and remove cost disincentives such as copays and deductibles.
Perhaps most importantly, patients need to embrace multidisciplinary, evidence-based programs and understand the inherent dangers and costs in long-term opioid use. One failure in the link will provide gaps that will perpetuate the enormous financial and societal costs of the opioid epidemic. Given that the coronavirus pandemic compounded pre-existing mental health disorders, reportedly led to opioid deaths in many parts of the United States and potentially more deaths of despair, now is the time to act. This is a tremendous opportunity for physicians, insurance companies and lawmakers to come together and create cost-effective, evidence-based care models that ultimately flatten the opioid curve.
Dr. Adam Bruggeman is a spine surgeon in Texas, board-certified in both orthopaedic surgery and addiction medicine. He is a member of the board of councilors for the American Academy of Orthopaedic Surgeons and the recent past president of the Texas Orthopaedic Association. Follow him on Twitter @DrBruggeman.