The opioid story across the United States is harrowing and costly. Harrowing in the tens of thousands of lives lost.
Costly in the billions of dollars spent, much of it on treatment and lost productivity. And employers and insurers are bearing the brunt of those costs.
Our drug epidemic has been fueled by prescription opioids, often for chronic pain. Even now—now that we know better—prescribing practices have barely changed. Doctors continue to treat chronic pain as a physical ailment, even when it’s not.
“The AMA, American College of Physicians, American Association of Orthopedic Surgeons—they are all saying there is a psychosocial component that drives chronic pain and doctors need to change their practices, but few are doing anything about it,” says Keith Rosenblum, senior strategist for workers compensation risk control at Lockton.
In many cases, a patient’s minor injury turns into long-term chronic pain and, ultimately, addiction.
“One company’s top 30 open claims dated back to the 1970s and ’80s,” Rosenblum says. “Why are they taking enough opioids that would kill an elephant?”
Lockton tried a couple years ago to meet with clients and look at the longest open claims. Over an 18-month period, the company reached out to specialists who were treating claimants and requesting prescriptions. Lockton asked to conduct a non-invasive pain assessment that would address the underlying source(s) of chronic pain. Eight out of 10 did not respond. Those who did, even in some cases where the pain was shown not to have a physical cause, refused to modify their treatment plans.
“So we thought, ‘This isn’t going to work. The science is there, but who’s going to listen to a broker?’” Rosenblum says.
Missing the Point
“The leading disabling condition of mankind is pain, worldwide,” Rosenblum says. “It’s essentially the number-one reason a person goes to the doctor.” The Institute of Medicine reports that in 2010 pain cost the United States between $560 billion and $635 billion.
The New England Journal of Medicine reported in March that chronic pain is among the most prevalent and debilitating medical conditions. More than 40% of older adults suffer from it.
“Given the prevalence of chronic pain and its often disabling effects, it is not surprising that opioid analgesics are now the most commonly prescribed class of medications in the United States,” the Journal reported. In 2014 alone, U.S. retail pharmacies dispensed 245 million opioid prescriptions.
“The urgency of patients’ needs, the demonstrated effectiveness of opioid analgesics for the management of acute pain, and the limited therapeutic alternatives for chronic pain have combined to produce an overreliance on opioid medications in the United States,” according to the Institute of Medicine, “with associated alarming increases in diversion, overdose and addiction.”
The epidemic has finally grabbed the attention of lawmakers, regulators and others, who are now trying to put mechanisms in place to curb doctors’ reliance on opioids. But, as Rosenblum says, everyone is missing the point. “Opioids are really a symptom,” he says. “They’re not the underlying problem.”
If pain is the leading reason for a visit to the doctor, the most common complaints are musculoskeletal, with back pain the most common. “Lockton’s large claims database indicates that low back injuries represent 20% of all loss dollars,” Rosenblum wrote in a 2015 white paper. “When looking at claims over $250,000, they represent 25%.”
Because back pain is so common and has such an effect on people’s lives, the healthcare community has considerably increased the use of certain diagnostic tools and treatments, including MRIs, spinal injections and lumbar fusions. Yet outcomes have not improved concurrently with the increased rate of treatment.
A 2009 study published in the Journal of the American Board of Family Medicine, titled “Over treating Chronic Back Pain: Time to Back Off?” said even when these treatments were successful, most patients continued to experience pain and dysfunction. And despite a rise in costs related to spine problems, people reported worse functional limitations, mental health, work limitations and social limitations in 2005 than in 1997.
The study also showed disability from musculoskeletal disorders is rising, not falling. Work disability attributed to musculoskeletal disorders—much of which is back pain—increased from 20.6% of beneficiaries in 1996 to 25.4% in 2005.
“Our problems have not resolved with all of the physical treatments and medications that we’ve put into place. So the underlying factors of chronic pain are not being addressed,” Rosenblum says. And insurers, and thus employers, are still paying.
One potential reason is the fundamental schism between the way pain is defined and the way it is diagnosed in America.
The Science of Pain
Pain is more complicated than it may seem.
“There are three factors in all of pain: the sensory-physical component, the emotional component and the experiential component (how we learn to deal with things, the context),” says Dr. David Ross, a Harvard-trained neurologist and chief medical officer at NeuroPAS Global.
In March, the U.S. Department of Health and Human Services released the National Pain Strategy, purported to be the federal government’s “first coordinated plan for reducing the burden of chronic pain that affects millions of Americans.” The plan contends many factors influence the way individual patients perceive and cope with pain. “Experiences, familial and genetic factors (including race, sex and gender), comorbidities, cultural background, and psychological, economic and environmental factors all play a role.”
These outside influences actually change the signals that are sent from the part of the body that has been hurt to the brain. The brain processes it and determines the body’s reaction.
To have the best chance of surviving, Ross says, “a caveman needed to know the difference between a cut caused by a thorn, a poisonous snake or a predator.”
But what if, in between the time he was hurt and recovered, the caveman’s brain received misinformation? Perhaps, just after he stepped on the thorn, a snake slithered past, and he mistakes the thorn cut for a snakebite. Does his response change?
“If I tell someone, ‘You’ve got a bad back and you’ve got herniated disks and the only thing we can do for you is surgery,’ I’ve given you a piece of information that is daunting and altering your life,” Ross says. “And that’s going to alter how you treat your back. You might become defensive about it, alter movements—you don’t want to make it worse. So you’re going to stiffen, not bend as much, become more sedentary. When you get that twinge, you’re going to worry about it. All of which is normal human behavior, and the question is: did the doctor get it right or wrong?”
This is where diagnosis comes in. Or, as research now shows, medical over-diagnosis.
“Red herrings and medical over-diagnosis are the main contributors to our declining improvement in managing large loss claims,” Rosenblum wrote in his white paper. “Employers are paying an ever-larger percentage of their workers compensation dollars on physicians’ less-than-effective efforts to relieve pain and distress by focusing treatment on the spine.”
Ross recalls his introduction to MRIs at Harvard back in the 1980s. “We had one of the first MRIs in Massachusetts,” Ross recalls. “We used to spend hours looking at these MRIs, at every anatomic thing with our oohs and aahs, thinking we had discovered the key. The problem was, we got it wrong. The herniated disk is just normal aging, and it’s harmless.”
Scientists agree. The 2009 study revealed inappropriate imaging “may result in findings that are irrelevant but alarming.”
Herniated disks, it noted, are common, even in people with no symptoms. What’s more, research shows a higher likelihood of surgery following imaging tests but not improved outcomes.
“But by telling people…that their life was changing and they had a serious problem, we were causing perceptual, behavioral pain,” Ross says. “As that got worse, we had to solve the problem.”
Why have doctors been relying so heavily on imaging? According to the 2009 study, the top reasons are patient demand, the compelling nature of visual evidence, fear of lawsuits and financial incentives. But perhaps one of the most compelling reasons is that doctors were taught to rely heavily on imaging.
“Pain is not studied scientifically in medical school,” Ross explains. “Most people get maybe an hour or two lecture on the science of pain. They deal with the body sensations, which are only part of the equation.”
The Institute of Medicine’s 2011 report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” concluded medical education programs should include a substantial amount of learning about pain and its diversity.
The National Pain Strategy says the current curriculum inadvertently encourages a “magic bullet” approach to treatment, which ultimately makes treatment futile. “When pain persists after the underlying cause is resolved, it may signal that pain-initiated changes in the central nervous system have occurred. If so, this chronic pain is no longer a symptom of another disorder and has become the disease itself.”
The physical pain becomes a psychological certainty.
A Mistaken Sign
Historically, opioids have fallen in and out of favor among healthcare providers. But a conservative approach to them throughout much of the 20th century led many doctors in recent decades to become concerned about the under-treatment of pain. Enter Dr. Russell Portenoy, an influential pain care specialist at Memorial Sloan-Kettering Cancer Center in New York. Having seen the effectiveness of opioids in treating cancer pain, Portenoy argued in 1986 that chronic opioid therapy was a safe alternative for treating much less severe but chronic pain.
It was the beginning of a major campaign to destigmatize opioids and portray the under-treatment of pain as an epidemic. It continued into the 1990s.
As president of the American Pain Society, Portenoy called on doctors to make pain the fifth vital sign. He said there was little risk of addiction or overdose among pain patients and less than 1% of opioid users would become addicted. The effort worked but for the wrong reasons.
“We didn’t do our homework,” Ross says. “And we all made the mistake, following his lead and the lead of others who I respected at the time. I did the same thing. I thought I had the answer. So I was giving all of this medicine. And it worked on some. It certainly works temporarily, not only on a sensory level, but opiates are a very powerful perception changer, which is why it’s addictive. So it worked on an emotional and on a perceptual/psychological level. Which is where its addictive properties come from. And it did diminish the experience of pain, through pleasure, calming, and possibly through some sensory changes. So it worked. For the wrong reasons. With devastating results.”
In 1996, Purdue Pharma released OxyContin, a form of the opioid oxycodone, in a patented, time-release form. But it had a fairly small market, explains Phil Walls, the chief clinical officer for pharmacy benefit manager myMatrixx. Taking advantage of the path Portenoy and others had forged, Purdue released a marketing video titled “I got my life back: Patients in Pain Tell Their Story.” The 1998 video, distributed to 15,000 doctors nationwide, featured patients in pain describing how OxyContin had greatly improved their quality of life.
Fast forward nearly 10 years. In 2007, Purdue Pharma and several of its executives pleaded guilty to “misbranding” OxyContin and paid roughly $635 million in fines. In 2012, the Milwaukee Journal Sentinel reported two of the seven patients in the video had died as active opioid abusers, a third had become addicted, suffered greatly and quit after realizing she was headed for an overdose. Three maintained the drug helped them cope with their pain and improved their quality of life. A seventh declined to answer questions.
Portenoy admitted to The Wall Street Journal in 2012 he gave misinformation about pain management, specifically about opioid therapy. “We didn’t know then what we know now,” he said. “I gave innumerable lectures in the late 1980s and ’90s about addiction that weren’t true,” he told a fellow doctor in a previously unpublished videotaped interview the newspaper reviewed. The Journal also reported that a 2007 fundraising prospectus showed Portenoy’s program received millions in funding over the preceding decade from opioid makers, including Purdue Pharma.
The damage was done. Opioid prescriptions increased from 76 million in 1991 to 207 million in 2013, at the same time becoming the leading workers compensation problem in terms of controlling indemnity losses.
“There has never been a more damaging impact on the cost of workers compensation claims from a single issue than the abuse of opioid prescriptions for the management of chronic pain,” Rosenblum wrote in 2012. “Nationally, an estimated 55% to 86% of all claimants are receiving opioids for chronic pain relief.”
Research shows workers prescribed even one opioid had average total claims costs four to eight times greater than claimants with similar claims who didn’t get opioids.
Perpetuating the Cycle
Many doctors were devastated to learn the truth behind their prescribing practices.
“The change of heart among former champions of opioid use has happened quietly, largely beyond the notice of many doctors,” The Wall Street Journal reported. “New York psychiatrist Joseph Carmody said he was ‘shocked’ after attending a recent lecture outlining the latest findings on opioid risk. ‘It goes in the face of everything you’ve learned,’ he said.
‘You saw other doctors come around to it and saying, oh my God, what are we doing?’” The Journal reported.
It’s a hard pill to swallow. And quite possibly, just as hard to change your ways.
“Doctors aren’t stupid people,” Ross says. “Anybody looking at the statistics can easily see something is very wrong, but why are the trends continuing to get worse? Because the incentives, mostly financial, do not help correct the trend.”
There are initiatives, many in the public sector at this point, to change that. But for now, many doctors make a living by seeing as many patients as possible and by keeping those patients. For some, Ross says, there isn’t really an incentive to resolve pain because then you lose a customer.
Walls mentions social media as an often unacknowledged contributing factor. “The next time your company goes through open enrollment, all of a sudden you are going to be out there looking for possibly a new physician. You’re going to go to the Internet and see what kind of ratings the physicians have in network. It’s just like everything else—hotel, restaurant, whatever—most of the time people don’t comment when they have a good experience. They only comment when they have a bad experience. And if an individual’s goal is to go to a physician to obtain drugs, if that doctor doesn’t provide those prescriptions, they get a bad review.”
Rosenblum sees these issues playing out in open claims. “I go get the medical notes from the first visit and guess what I find? Clearly, boldly in the medical history—currently taking medication for anxiety. History of depression. Smoker. Those are clear warning signs, indicators. Yet, time and again, I mean this almost universally,” he says, “there’s no indication that the physician has looked elsewhere beyond the patho-anatomical source of pain, the physical sensory source of pain.”
“Many physicians,” says the New England Journal of Medicine, “admit that they are not confident about how to prescribe opioids safely, how to detect abuse or emerging addiction, or even how to discuss these issues with their patients.”
“We are a society that expects a cure for everything,” Walls says. “There very much is a feeling that no one should be in pain. Not that anyone should suffer, but I don’t think we should have an expectation that we should live completely pain free. It’s just not going to happen.”
increase in Medicare expenditures for epidural steroid injections between 1994 and 2001
increase in expenditures for opioids for back pain between 1997 and 2004
increase in the number of lumbar MRIs among Medicare beneficiaries between 1994 and 2005
increase in spinal fusion surgery rates between 1988 and 2001
Source: Journal of the American Board of Family Medicine
These factors have created a billion-dollar problem for insurers and employers. A 2007 study in the journal Pain Medicine said total U.S. societal costs of prescription opioid abuse were $55.7 billion. Workplace costs of prescription opioid abuse accounted for $25.6 billion, 46% of the total. A 2016 study by Castlight Health found nearly a third of opioid prescriptions purchased through employer-sponsored insurance are being abused.
“Ultimately the people paying for this are the taxpayers and the corporations,” Ross says. “It’s really up to the brokers who are the educators to get to the people they have allegiance to—the employers—to tell them they are wasting money and losing productivity needlessly.”
Ross has been trying for more than a decade to get this message across. After doing neuromuscular research at the University of Miami, he went into private practice as a neurologist.
In his first year or two, he saw 600 to 700 patients, many of them referrals from orthopedists. “I was doing EMGs”—electromyography—“trying to diagnose them,” Ross says. “But what immediately struck me is that it didn’t fit. There was something else going on. I realized that I was missing something.”
Ross thought a lot of the pain could be muscular. “So I started treating muscles, and people started getting better.” He wrote a paper on the muscle component of pain and neuropathy, which subsequently won an award from the University of Louisville. And for the next 10 years, he says, “I just played with my own ideas.”
In 2004, Ross developed a device that could evaluate pain and prove whether it was sensory, perception or simply made up and—if it was sensory pain—whether it was muscle, nerve or joint. He calls it a Neurophysiologic Pain Profile Assessment. The device won a 2006 honorable mention from The History Channel’s Modern Marvels. “I was happy,” Ross says. “I thought I had solved the problem.”
He took his device to his mentors at Johns Hopkins, to Harvard, the University of Miami and the Mayo Clinic. “Nobody wanted it,” he says. Finally, he says, one of the neurologists clued him in. “Nobody wants to know that 80% of their surgeries aren’t necessary.”
The federal government has made it clear the current opioid epidemic has been driven by prescribing practices and has undertaken numerous initiatives to curb it.
In March, the Centers for Disease Control and Prevention issued voluntary guidelines to cover the following:
- Determining when to initiate or continue opioids for chronic pain
- Opioid selection, dosage, duration, follow-up and discontinuation
- Assessing risk and addressing harms of opioid use.
The Obama administration has undertaken several other initiatives. Among them:
- A National Drug Control Strategy directs the Department of Health and Human Services to assist healthcare providers and first responders with training to respond to overdoses and supports the overdose reversal drug naloxone.
- An action plan seeks to reduce opioid overdose deaths by 15%. It supports expanding state-based prescription drug monitoring programs, training healthcare providers to properly prescribe opioids, and educating patients on the consequences of prescription drug misuse. The plan also calls for reducing the prevalence of pill mills and doctor shopping.
- Directing federal public health and safety officials to increase data sharing and identify trends in substitution between prescription painkiller misuse and heroin use.
States also have an important role in regulating opioid prescriptions. Among other services, states run prescription drug monitoring programs and workers comp programs.
Many states have taken action to require prescribers to check a state’s monitoring program before prescribing opioids. Other states have implemented closed formularies for workers comp, which means certain drugs (including opioids) require prior approval before a doctor can prescribe them. Some have capped the strength and duration of opioid prescriptions.
The state of Washington has gone so far as to severely limit coverage of lumbar fusion surgery by state healthcare programs.
Keith Rosenblum, a senior strategist for workers compensation risk control at Lockton, favors most of these regulatory changes. But he asks: “Then what? So then the physician is left with, ‘I can’t give them the drugs. They’re still complaining of pain. What else do I do?’
“We now have 26 states in which patients are authorized to take medical marijuana. So they dump opioids and they prescribe medical marijuana, and that’s not going to do it either. Somebody’s got to open the discussion around why they are prescribing opioids in the first place.”
Phil Walls, the chief clinical officer for pharmacy benefit manager myMatrixx, agrees. “What really concerns me is we’re seeing a decrease in the use of prescription opioids, but the reality is some of these patients are turning to street heroin,” Walls says. “Those are the people who are being underserved because they actually make the statistics look better. Once people are on the street, no one is tracking those numbers anymore. They fall through the cracks.”
Who’s Going to Listen to a Broker?
Meanwhile, Rosenblum was frustrated. Lockton’s data showed claims greater than $50,000 account for 7% of claims and 71% of incurred dollars. Meanwhile, claims greater than $100,000 account for 3% of claims and 52% of incurred dollars.
So he and his team began formalizing the research, collecting hundreds of articles from the scientific community that detailed the emerging research on chronic pain. It was during this time that he discovered Ross’s device. “I found Ross’s technology was the only one that could essentially assess where the source of pain was,” Rosenblum says. Lockton began experimenting with half a dozen clients “with incredible results.”
Rosenblum then put together an advisory board of doctors, clinical psychologists and claims professionals. The board’s purpose, Rosenblum says, was “to identify and target indemnity losses with early warning signs for delayed recovery while claimants are still being treated by their primary care providers, typically within the first two to six weeks, before medical care moves in an irreversible and potentially inappropriate direction.”
Out of this has come Lockton’s Biopsychosocial Injury Recovery Model (BIRM), a detailed strategy that maps out a process for finding the right diagnosis and treatment for an injured employee. The process includes early evaluations using Lockton’s predictive tool for delayed recovery indicators and, if indicators show the potential for chronic pain, NeuroPas Global testing using Ross’s device. From there, the process directs the patient to the appropriate therapy, which ranges from continued physical therapy to a full health and behavioral evaluation.
Lockton has been speaking with a number of large employers and is now starting a year-long pilot of this model. “Every single one was wowed,” Rosenblum says, as they finally began to understand why such a small percentage of claims, many of which had started as minor back injuries, accounted for more than half the company’s loss dollars.
“We said, ‘There is a way to navigate this, and we’re going to put it out there to the world.’ Somebody has to make a difference,” Rosenblum says. “And we are making a difference.
There’s no financial compensation for giving our clients the model. We absolutely believe this is going to make an impact. I believe it is going to be the workplace, the employers, the insurance industry and the medical industry associated with occupational medicine that are going to drive the change.”
Foiled by His Beliefs
The pain evaluation device created by Dr. David Ross, the chief medical officer at NeuroPAS Global, works by measuring two things: autonomic responses and muscle activity.
Autonomic responses include heart rate, blood pressure volume and skin resistance. They are measured via electrodes that calculate the pulse, the blood flowing through the fingers, and the “sweating response,” which signals the fight-or-flight response system. Muscle activity is measured via sensors that respond to movement or tension.
A technician first measures these responses in a part of the body that does not have pain, recording the patient’s baseline fight-or-flight response. Then the technician measures them in the area that is tender. “If it’s really tender and physical, then you’re going to get the same sort of reaction at a much lower intensity,” Ross explains.
“Now, if you’ve got an emotional issue and you’re protecting yourself, you’re going to jump before or after. If you start reacting before I press on you, I know that you’re reacting to a stimulus independent—fear, anxiety. Before you actually have the sensation level where your nervous system reacts, your perception of it is generating the experience. If I do it and you don’t react at all, then I know you’re not tender, you’re not emotional. There are only two possibilities left—there’s something deeply psychological and you’re avoiding the whole situation or you’re making it up. I can tell what the mix is, and I know what to do.”
He cites one success story. One day, while chasing a dog that had nipped at his daughter, Ross fell hard, “hard enough to put a hole in the drywall. It really hurt. I thought I sprained my ankle.” He spent the day in a wheelchair, then a week on crutches. Eventually he learned he had partially torn his Achilles tendon. He opted not to get surgery, but to instead let it heal. And when it did, “I had partial atrophy of my leg, so I had some mild chronic pain. And whenever it was cold out, whenever I walked too far, it would ache. And I gave up tennis.”
Six years later, Ross was installing his machine at the Mayo Clinic for a test. It was a cold day and he had far to walk, so his leg got sore. Since he had to train the clinic tech and he was feeling pain, he jumped up on the table and offered to be the guinea pig. “And lo and behold, to my surprise, it showed me an emotional response, with little tenderness. I said to the new technician, ‘I don’t know what you did wrong, but that’s not me.’”
An hour later Ross repeated the test with his own technician—same response, mostly emotional. “I thought about it for the next couple of days, and I realized that my training had built up a false belief system. I had lost part of my tendon. I had weakened my leg in my ideas, and therefore, protectively, if I overdid it, I would hurt myself and need surgery. So I had done something called fear avoidance. Psychologically what I had done was protected myself against danger or re-injury. Even though it wasn’t real. I had put a snake in my own bed.”
Once Ross had this realization, he gradually began working out his leg. Roughly six months later, his pain was “much, much better,” his discomfort was 80% to 90% gone, and he was back to tennis.
“Everyone would have diagnosed me as having a good recovery. Here I was, a Harvard-trained neurologist, interested in pain, inventor of an award-winning machine. But when it came to understanding my own pain, I got it wrong because of my training. My belief system overcame the biology. And it was only when I could understand the two that I was able to find the key and improve.”