There was a time when opioids were used exclusively to help manage the pain of cancer, palliative care and end-of-life patients, not the litany of ailments they are often prescribed for today.
For C-sections, chronic pain, fractures, contusions, dental surgery, foot surgery and more, physicians typically used non-opioid alternatives to treat their patients.
In the late 1990s, the world changed dramatically as pain was officially recognized as the fifth vital sign. Many physicians became more comfortable prescribing opioids to a plethora of patients, and medical students and physicians were told that opioids were not addictive (i.e., the benefits outweighed the risk of addiction in chronic pain), largely driven by a surge in opioid marketing campaigns. By 2012, healthcare providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills.
With over 52,000 Americans dying from drug overdoses in 2015, and approximately 63% of those deaths involving the use of opioids, the consequences of these practices have become much more real. It is important to take a harder look at non-opioid alternatives that could be used to help to reduce the chance that patients will become dependent or addicted to opioids.
Survey-based screening tools
Screening tools for opioids have been around for decades. One of the most common tools in use is called the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). SOAP-R is a tool for clinicians to help determine how much monitoring a patient on long-term opioid therapy might require.
The survey questions can be filled out in less than 10 minutes by answering 24 questions such as: How often do you have mood swings? How often do you feel bored? How often have you felt a craving for medication? The tool is administered by clinicians to patients at their initial visit and various studies have shown the tool to be effective in carefully predicting substance misuse.
Another tool, the Opioid Risk Tool (OPT) invented by Lynn Webster, M.D., can be completed by a patient in less than five minutes. The OPT scores patients based on their gender and a series of five questions focused on whether the patient and the patient's family has a history of substance abuse, age being from 16-45, a history of preadolescent sexual abuse, and the existence of psychological diseases (e.g., attention deficit disorder, obsessive compulsive disorder, bipolar, schizophrenia and depression). The tool has been effective in pilot studies of correctly predicting which patients were at the highest and lowest risk of exhibiting aberrant, drug-related behaviors associated with abuse or addiction.
These tools, as well as the new opioid prescribing guidelines shared by the CDC and various states, offer good alternatives to prescribing opioids.
Predictive models of tomorrow
It's not news that the use of advanced analytics has been on the rise across many industries, especially in the insurance industry. A number of companies are using predictive models and behavioral health screens to assess an individual's risk for dependency, and steering some injured workers to non-opioid alternatives.
A Deloitte Consulting LLP article focused on reversing the opioid epidemic. Opioid predictive models were described which focused on helping to prevent opioid dependency and addiction before the habits ever form. Utilizing data such as co-morbidities, job classes, injury causes, business characteristics and claim characteristics, the opioid prevention model is run at the three-point contact between the employer, injured worker and physician to predict the number of opioid supply days that an injured worker might consume.
Armed with the predicted supply days and reasons driving the highest scores, insurance companies can utilize prescribing guidelines and peer-to-peer contact between the insurance company physician and prescribing physician to help improve the care of the injured worker; this ultimately minimizes the chances that they will be long-term users of opioids.
As more and more patients become addicted to opioids for pain relief, physicians are looking for alternative options. (Photo: Shuttestock)
Americans have been using non-opioid medications, like ibuprofen, aspirin, pregablin and antidepressants, to treat pain for many years. In the CDC flyer, Nonopioid Treatments for Chronic Pain, CDC guidelines clearly state that “Opioids are not the first-line therapy for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Evidence suggests that non-opioid treatments, including non-opioid medication and nonpharmacological therapies can provide relief to those suffering from chronic pain, and are safer.” These guidelines list a number of effective approaches to managing chronic pain, the first on the list being the use of non-opioid therapies to the extent possible.
For lower back pain, the CDC recommended treatments include: 1) Self-care and education in all patients; advise patients to remain active and limit bed rest, 2) nonpharmacological treatments: exercise, cognitive behavioral therapy, interdisciplinary rehabilitation, and 3) medications — first line: acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), second line: serotonin and norepinephrine reuptake inhibitors (SRNIs)/tricyclic antidepressants (TCAs).
Acupuncture is a form of Chinese medicine that puts very thin needles into a patient's skin at certain points in the body to help alleviate pain and treat various physical, mental and emotional conditions. Although acupuncture has been utilized as a pain management strategy for more than 3000 years, it is still viewed mainly as a complementary therapy in the U.S. Some skeptics argue that acupuncture success is hard to test, especially when it comes to establishing controls; however, several randomized control trials (RCTs) and meta-analyses have been able to verify the effectiveness of acupuncture in managing pain.
One acupuncture application validated by RCT was for the treatment of chronic shoulder pain. A 2010 trial randomly allotted 424 outpatients who suffered from chronic shoulder pain among Chinese acupuncture, sham acupuncture or conventional conservative orthopedic treatment. The results suggested that the Chinese acupuncture treatment was superior to the conventional treatment. Moreover, descriptive statistics illustrated that acupuncture more broadly was an effective orthopedic treatment for chronic shoulder pain.
Additional RCTs conducted to assess effectiveness of treatment for other types of pain have similarly yielded positive outcomes. In 2013, a multicenter, randomized, controlled, comparative effectiveness trial assessed the effects of motion style acupuncture treatment (MSAT) on acute lower back pain with severe functional disability. The trial also produced results that suggested MSAT is effective for both immediate pain relief and for functional recovery.
Massage therapy has grown in popularity over the past decade as both a complementary and an alternative form of pain management. Although some still question whether massage therapy is as effective in reducing pain as some of the other treatments, clinical evidence suggests that massage therapy can be recommended as a pain management option.
Massage therapy is another example of a team-centered approach to patient care. It enables the patient to build a relationship with the practitioner, and tailor treatment to specific pain points. Integration of massage therapy into acute care settings, for instance, has heightened patients’ abilities in dealing with the challenging physical and psychological pieces of their health conditions. Reduction in pain levels, interrelatedness of pain, relaxation, sleep, emotions, recovery, and the healing process have all been observed through this form of treatment.
Maintaining a healthy lifestyle through regular exercise, good food choices and other strategies provides multiple benefits for patients and can help in pain management. (Photo: Shutterstock)
Lifestyle adjustment: Physical activity, nutrition and weight loss strategies
Physical therapy is recommended by the CDC as a potential substitution for opioids, and is often prescribed in tandem with other forms of exercise and/or dietary adjustments. There's positive evidence that select physical modalities are effective in managing chronic pain. Studies support the use of therapeutic exercise in the treatment of pain, but the selection of the appropriate physical modality should depend on the desired functional outcome for the patient. The bulk of research has tested the effect of physical modalities on chronic back pain and osteoarthritis knee pain, but physical therapy is currently used to treat a broader spectrum of pain sources ranging from arthritis and fibromyalgia to chronic headaches.
When it comes to holistic treatment of pain, various lifestyle adjustments — ranging from diet to exercise — have also been shown to reduce the burden of chronic pain. Omega-3, vitamin D, magnesium and turmeric have all been flagged as supplements that could potentially help with pain management. Consumption of over three grams of EPA/DHA omega-3 fatty acids has been shown in some studies to reduce pain. Vitamin D decreases inflammation and increases bone density; in contrast, low levels of Vitamin D have been correlated with a two-fold increase in opioid use and duration of use. Magnesium works as a muscle relaxant because it inhibits the release of acetylcholine (ACh) from motor end plates. Turmeric has exhibited analgesic properties; in addition to reducing pain, it can also reduce fatigue.
These supplements are most effective when combined with other healthy living habits, such as eating lots of vegetables and limiting the intake of caffeine. Physical activity has also been found to reduce pain severity, and produces a cognitive effect that further assists in the patient's cerebral and emotional management of pain. Yoga, for example, utilizes a series of mind-body techniques and also incorporates meditation. In studies, the combination of physical activity and yoga appear to exert a protective effect on the brain's gray and white matter that could counteract the negative neuroanatomical effects of chronic pain.
Cognitive behavioral therapy (CBT)
CBT is a form of talk therapy that helps people identify and develop skills to change negative thoughts and behaviors. CBT can be used in combination with other non-opioid alternatives to help control pain. In the Deloitte University Press article, “Think slower: How behavioral science can improve decision making in the workplace,” the authors describe how CBT is helping people recognize the circumstances around their negative thoughts, and consequently, slow them down to engage in more positive behaviors. The article recounts how CBT was used to help injured workers with mental health issues such as depression return to work on average sixty-five days earlier, saving $5,275 per employee.
According to WebMD, nerve ablation is a method that may be used to reduce certain kinds of chronic pain by preventing the transmission of pain signals. The procedure destroys or removes a portion of nerve tissue, causing an interruption in pain signals and reduces pain in that area. Nerve ablation can be achieved using heat, cold or chemicals.
Although physicians in the U.S. have a long way to go when it comes to lowering opioid prescriptions for pain management, there are encouraging signs that more physicians are using non-opioid treatments to effectively address pain. One of the largest health care systems in Tennessee announced that it will no longer prescribe long-term opioid pain medication at two of its pain management clinics, opting to focus their efforts on using non-opioid alternatives.
One of the country's busiest emergency rooms in New Jersey has decided to use opioids as a last resort when treating patients with common types of acute pain. In March 2016, the CDC released their new prescribing guidelines which noted that when opioids are used for acute pain, clinicians should prescribe the lowest dose of immediate-release opioids. More importantly, the CDC noted that three days or less will often be sufficient; more than seven days will rarely be needed. These guidelines have led to a number of states limiting the first-time prescriptions of opioids to seven days.
With the National Safety Council survey results showing that 99% of doctors prescribe opioids longer than the CDC recommends, it's time to reconsider the use of non-opioid alternatives. If patients clearly understood the risk of taking opioids, and if prescribing physicians focused more on explaining non-opioid alternatives, our healthcare system could go a long way toward stemming the opioid epidemic.
Pedro Arboleda (firstname.lastname@example.org) is a managing director at Deloitte Consulting LLP in Boston, Mass., and is focused on assisting clients in creating public-private partnerships to solve societal issues in the health sector. Kevin M. Bingham, ACAS, MAAA, (email@example.com) is a principal at Deloitte Consulting LLP in Hartford, Conn., and leader of the Claim Predictive Modeling and Medical Professional Liability practices. Randy Gordon, MD, MPH, (firstname.lastname@example.org) is a managing director at Deloitte Consulting LLP in McLean, Va., and leads Deloitte's Quality and Patient Safety practice. Alanna Hughes, MBA, MPA, (email@example.com) is a senior consultant at Deloitte Consulting LLP in Boston, Mass., who focuses on cross-sectoral solutions to pressing health and economic development challenges.