The Business of Opiates and Chronic Pain

Posted by Albert Holt, MD on March 17, 2011 under Pain | Be the First to Comment

Recently, Alex Swedlow and his colleagues at the California Workers Compensation Institute (CWCI) published a study that will be presented at their annual meeting in San Francisco next week.  In this study, they report on the prescribing patterns of California workers’ compensation medical providers who write Schedule II prescriptions.  CWCI has previously reported on the large increase in narcotic prescription filled as part of workers’ compensation claims, growing from 1% to 6% of prescriptions filled.  That six-fold increase in prescriptions has resulted in a more than six fold increase in prescription drug payment, increasing from 3.8% to 23.6% of total prescription drug payment in the California workers’ compensation system.  All of this is occurring despite warnings from the US Department of Health and Human Services Office of the Inspector General that these drugs cause “severe psychological or physical dependence if abused.”

There were 9,174 Schedule II opiate prescribing physicians in the study.  The top 1% (93 physicians) accounted for nearly one third of the prescriptions, as well as 41% of the morphine equivalents and the associated payments.  Translated into dollars, that is $36.5 million in payments for Schedule II narcotics.  The top 3% accounted for more than half (54.9%) of the prescriptions.  The top 10% of injured workers who were accounting for the opiates obtained their prescriptions from an average of 3.3 physicians. 

How big is the problem of opiates in chronic pain?

■     More than one-quarter of Americans (26%) age 20 years and over—or, an estimated 76.5 million Americans—suffer from chronic pain

■     Admission rates for abuse of opiates other than heroin—including prescription painkillers—rose by 345% from 1998-2008

■     20% of workers’ compensation medical costs of fully developed claims are spent on prescription drugs; narcotics account for 34% of this spend

■     120,000 Americans a year go to the emergency room after overdosing on opioid painkillers, according to Laxmaiah Manchikanti, chief executive officer and board chairman for the American Society of Interventional Pain Physicians

Pain management has become an industry for some, as evidenced by the high opiate prescribing patterns of some physicians in the CWCI study.  In addition, the pharmaceutical industry has profited from the “off-label” use of both narcotic drugs and non-narcotics.  Take Actiq (Fentanyl “lollipops”) as an example.  Actiq had a very specific indication from the FDA—for breakthrough cancer pain.  At $65 per lollipop, it is the most expensive oral narcotic prescription.  In 2006, oncologists (cancer physicians who would be prescribing them for the indicated use) were writing only 1% of the prescriptions for Actiq.  Instead, 80% of the prescriptions were being written for back pain and migraines in 2006.  The number one cost category for Schedule II opiates in Swedlow’s study was for the diagnosis of back pain.

According to the Model Policy for the Use of Controlled Substances for the Treatment of Pain by the Federation of State Medical Boards of the United States, “physicians (should) incorporate safeguards into their medical practices to minimize the potential for abuse and diversion of controlled substances.”

Ethical experts who treat chronic pain patients, like Fernando Branco, MD, at the Rosomoff Comprehensive Pain Center in Miami, Florida, recognize the dangers of opiate addiction and provide treatment programs with the following goals:

• Improve quality of life
• Restore optimum levels of function
• Reduce or eliminate pain
• Reduce or eliminate addictive pain medications
• Enable independence from the healthcare system (related to pain)

The following is the progression of pain as a chronic problem and the downward spiral that can result:

Unraveling the biologic, psychological and social components of chronic pain in injured workers has been the Paradigm approach.  This proven methodology has resulted in better pain management, high return to function and work rates, the reduction and elimination of opiate use, and a substantial reduction in costs.  We need to be careful as we look at pain therapies for the evidence that there is a long-term benefit and not some quick fix (which is usually tied to a substantial revenue generation for the provider).  From a clinical and financial standpoint, we need to use the tools that provide comprehensive assessment and management of chronic pain patients in order to achieve long-term opiate free pain control.

Next week, one of our pain physician specialists will discuss addiction and pain in more detail.