A Healthesystems publication

Fall 2013

Beyond Opioids: Alternative Pain Management Therapies

The medical community is making an effort to gain a better understanding of complementary and alternative medicine therapies and integrate them into treatment protocols. These therapies could end up being cost savers and deliver a better result for injured workers.

As state legislators enact stricter regulations around opioid use and workers’ compensation payers recognize that long-term opioid use creates long-term complications. Better ways to manage chronic pain are being considered. No longer can providers rely solely on the magic bullet of opioid therapy to treat chronic pain. The number of patients turning to complementary and alternative medicine (CAM) therapies for pain relief is rising, but this popularity has yet to result in a parallel increase in acceptance and use within traditional medicine.1 A closer look at these modalities may be warranted.

Complementary medicine therapies are used in concert with conventional medicine. As the name implies, alternative medicine therapies are used in place of conventional medicine.

CAM therapies employed for chronic pain relief include: 

The medical community is making an effort to gain a better understanding of CAM modalities and integrate them into traditional medicine protocols.  Funded research on complementary and alternative medicine therapies is now recognized by the National Institutes for Health. The Pain Management Task Force commissioned by The Office of The Army Surgeon General studied a number of CAM therapies and made recommendations for incorporating them in to pain management protocols in its Final Report published May 2010.2

Patient-Centered Care

In a traditional medical model, a patient presents a complaint of pain to a provider and may be given a prescription for a medication. The patient’s responsibility is to take the medication. He or she is a passive participant in their own care. This can lead to recurrent cases of poor outcomes, problems with multiple prescriptions, and some patients’ disillusion with the medical system.3

The integrative model takes a whole person approach and focuses on self-care, self-responsibility and self-awareness. In February 2009, the Institute of Medicine acknowledged patient-centered care as one of the five critical dimensions of high-quality care. Research shows that focusing the health care system around the patient can improve patients’ satisfaction with care and clinical outcomes.  Patient-centered care empowers the patient to be responsible and participatory in his or her health and healing process, which can improve patient functionality.4,5   

The integrative model approaches pain control from multiple areas of a patient’s life. It includes a multidisciplinary team approach that encompasses:

The Army’s Pain Management Task Force recommended 13 modalities of complementary and alternative medicine therapies and stressed self-help by incorporating active phases for each.  Yoga is brought into the therapy regimen through facility-based classes — a passive method of providing therapy. The patient is later transitioned to self-directed yoga through videos — an active method.  

Cognitive Behavior Therapy

Treatment guidelines for the management of chronic low back pain published by the American College of Physicians and the American Pain Society include first-line recommendation for cognitive behavior therapy (CBT).7 CBT provides coping skills for managing the psychological aspect of pain.  It incorporates such tools as biofeedback and may be particularly useful in patients with high levels of anxiety associated with pain, who may be prone to pain catastrophizing.8,9 

Patients who are educated and understand that they may continue to have some pain often experience improved functionality, especially if they are involved in treatment planning.10    

Effectiveness

A study funded by the National Institutes for Health through the National Institute on Drug Abuse surveyed 908 patients using opioids to control chronic pain and found that nearly half were also using some form of complementary and alternative medicine therapy.11

Are these therapies effective? According to patients in the study, the answer is yes, though medical science does not fully understand how some of these therapies work.12 

Less Costly Over Time

Despite growing evidence, complementary and alternative medicine protocols are not widely used.13,14  Perceived costs may be one factor.  The lack of in-depth study on efficacy may be another.  When the true costs of long-term opioid therapy are weighed against the cost of complementary and alternative therapies such as massage, acupuncture and chiropractic therapy, payers might consider incorporating CAM modalities to improve pain treatment and prevent the more costly consequences related to opioid use.  

Spending in the U.S. in 2005 across federal, state, and local governments for the treatment of substance abuse and addiction was estimated at $467.7 billion and was over 10 percent of the combined governmental budget of $4.4 trillion. A 2010 Medicaid study compared costs of opioid therapy abuse. This analysis found that total costs for patients with opioid use or dependence were 68 percent higher than costs for the matched control group.15  

A study published in 2010 in the Journal of Alternative and Complementary Medicine found that the average cost per patient was less for complementary and alternative medicine users versus nonusers with an average savings of $1420 per patient.16  

According to the 2012 findings by The Accident Fund and Johns Hopkins University, a study of 1,200 workers’ compensation claims in Michigan over a four-year period revealed that the cost of claims where long-acting opioids were prescribed were nearly 3.9 times more likely to exceed $100,000 than claims without such prescriptions.17 

 

Summary

At first glance, complementary and alternative medicine therapies may be perceived to be a more costly means of controlling chronic pain. These therapies are often needed for a shorter duration than opioid therapy so their overall costs could be lower than opioid therapy. Healthesystems invites payers to take a closer look at complementary and alternative medicine therapies. These therapies could end up being the true cost savers and deliver a better result for the injured worker and employer.

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SOURCES

1 -Fleming S, et.al. CAM therapies among primary care patients using opioid therapy for chronic pain, BMC Complementary and Alternative Medicine 2007, 7:15, available at www.ncbi.nlm.nih.gov/pmc/articles/PMC1885447/ , accessed September 9, 2013.
2 -DoD/VA Pain Management Task Force. Providing a standardized DoD and VHA vision and approach to pain management to optimize the care for warriors and their families. 2010. Available at: www.armymedicine.army.mil/reports/U.S._Army_Pain_Management_Campaign.pdf . Accessed August 4, 2013.
3 -DoD/VA Pain Management Task Force. Providing a standardized DoD and VHA vision and approach to pain management to optimize the care for warriors and their families. 2010. Available at: www.armymedicine.army.mil/reports/U.S._Army_Pain_Management_Campaign.pdf . Accessed August 4, 2013.
4 -Maizes V et. al. Integrative Medicine and Patient Centered Care, Institute of Medicine Summit on Integrative Medicine and the Health of the Public, February 2009. Available at www.iom.edu/~/media/Files/Activity%20Files/Quality/IntegrativeMed/Integrative%20Medicine%20and%20Patient%20Centered%20Care.pdf , accessed September 15, 2013.
5 -Keefe, F. J., M. E. Rumble, C. D. Scipio, L. A. Giordano, and L. M. Perri. 2004. Psychological aspects of persistent pain: Current state of the science. Journal of Pain 5(4):195-211.
6 -DoD/VA Pain Management Task Force. Providing a standardized DoD and VHA vision and approach to pain management to optimize the care for warriors and their families. 2010. Available at: http://www.armymedicine.army.mil/reports/U.S._Army_Pain_Management_Campaign.pdf . Accessed August 4, 2013.
7 - Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Int Med.2007;147:478-491.
8 -Smeets RJ, et. al. 2006. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. Journal of Pain 7(4):261-271.
9 - Buse DC and Andrasik FA. 2010. Headaches in primary care. In Handbook of cognitive behavioral approaches in primary care, edited by R. A. DiTomasso, B. A. Golden, and H. Morris. New York: Springer Publishing Co. Pp. 655-677.
10 -Keefe, F. J., M. E. Rumble, C. D. Scipio, L. A. Giordano, and L. M. Perri. 2004. Psychological aspects of persistent pain: Current state of the science. Journal of Pain 5(4):195-211.
11 -Maizes V. et al. Institute of Medicine Summit on Integrative Medicine and the Health of the Public. Integrative Medicine and Patient-Centered Care. February 2009. www.ncbi.nlm.nih.gov/pmc/articles/PMC1885447/ , accessed September 9, 2013.
12 - Fleming S. et al. BMC Complement Altern Med. 2007; 7: 15. May 2007. CAM therapies among primary care patients using opioid therapy for chronic pain. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1885447/ Accessed August 4, 2013.
13 -Kerns RD, et. al. 2008. Psychological interventions for chronic pain. In Proceedings of the 12th World Congress on Pain, edited by J. Castro-Lopez. Seattle, WA: IASP Press. Pp. 169-181.
14 - Kerns RD, et. al. 2011. Psychological treatment of chronic pain. Annual Review of Clinical Psychology 7:411-434.
15 -McAdam-Marx CCL, et. al. Costs of opioid abuse and misuse determined from a Medicaid database. Journal of Pain & Palliative Care Pharmacotherapy. 2010.24(1):5-18.
16 -Lind BK., et. al. Comparison of health care expenditures among insured users and nonusers of complementary and alternative medicine in Washington State: A cost minimization analysis. Journal of Alternative and Complementary Medicine. 2010. 16(4):411-417.
17 -White, J. A., Tao, X., Taireja, M., Tower, J., & Bernacki, E. (2012, August). The effect of opioid use on workers’ compensation claim cost in the state of Michigan. Journal of Occupational and Environmental Medicine, 54(8), 948-953
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