The immense human toll of the opioid epidemic has policymakers at every level of government grasping for solutions. Unfortunately, the same sense of crisis that can help spur action has also led to poor policy proposals that threaten to do more harm than good.
Oregon has taken a very hard line on the issue with an initiative that, if passed, would force people on the state’s Medicaid plan to “taper off” all opioid-based treatments by 2021.
The move has met with understandable backlash from chronic pain sufferers, who credit their responsible use of the drugs with making their conditions bearable. Many fear that closing off access to legal, prescribed opioids would simply drive individuals to more dangerous alternatives. Yet states across the country are already looking to Oregon’s harsh measures as a model for potential action.
This could be a calamity. If we really want to limit the irresponsible use of opioids while preserving their availability for the people who most need them, it’s time to shift the focus from the prescriptions to the prescribers.
The Center for Disease Control (CDC) has released new physician guidelines (PDF) for the responsible prescription and monitoring of opioid use in patients. More specific and comprehensive than past years’ recommendations, the CDC’s new guidelines lowered the dosage threshold (PDF) at which providers were advised to exercise caution, gave specific recommendations on balancing the risks with the benefits when prescribing opioids to particular populations, and concentrated on monitoring all patients for opioid tolerance or dependency, not just those deemed “high-risk.”
The guidelines are firm but sensible. They emphasize patient education, designate previously “alternative” treatment measures as physicians’ first recourse in treating pain, and admit that there are indeed instances in which opioids provide an optimal solution for short-term pain management.
So why is the country still facing epidemic proportions of opioid addiction and death?
Simply put, most doctors don’t adhere to these guidelines because the entire system provides the wrong set of incentives. The national opioid epidemic did not occur in a vacuum. It began with the devaluing of primary care and has been exacerbated by the many misaligned interests in the health industry. Today, primary care in volume-centric health systems now serve as little more than a wheelhouse of referrals for unnecessary procedures, painful surgeries and “quick-fix” prescriptions like opioids that get patients in and out of the hospital quickly at the expense of putting them on the fast track to addiction.
The good news is that when prescribers follow CDC guidelines, there is no opioid addiction problem according to Mike Vasquez, who previously founded a rehab center organization and founded an opioid clinical management company. We can take a major step forward in addressing this crisis by turning the CDC’s guidelines into requirements and enforcing them by using the power of state health plan eligibility as leverage.
If doctors are unable to participate in state insurance markets and their corresponding federal reimbursement programs unless they can demonstrate good-faith adherence to the CDC’s guidelines, we might see two positive, industrywide changes as a result. Obviously, we could expect doctors to be more cautious when prescribing, continuing and increasing dosages of dangerous opioids to their patients. A still broader transformation, however, may also occur in the way we design and implement federal incentive payments and procedure-based, “fee-for-service” reimbursement models.
States can also give doctors a nudge by providing better information. Recently a research team led by experts at the University of Southern California noted that opioid prescription rates declined dramatically when doctors were informed that their patients had died of an opioid overdose.
While the vast majority of doctors have no financial incentive to get their patients addicted to opioids, they’re also currently receiving few signals that they need to re-evaluate how they prescribe these medications. That can change when we incentivize insurers to cover evidence-based, non-opioid treatments as a recourse for chronic pain, redesign our requirements for participation in state and federal payment programs and notify doctors when tragedy does strike.
Only then can we turn off the spigot that’s currently draining our system of dollars and flooding it with opioid prescriptions, overdoses and deaths—stemming the tide of the opioid crisis once and for all.