As views change on opioids, patients and providers find few other options for managing pain

In 2001, Mariah O'Brien was severely injured when the car she was riding in was hit by a vehicle traveling 70 mph on a Chicago expressway.

“I broke my neck in two places and my pelvis and my right leg,” she said. “I was flat on my back for three months and was on a lot of Vicodin at that point.”

O'Brien, 39, was prescribed the powerful pain reliever a second time last September after undergoing two surgeries to repair a torn anterior cruciate ligament. Both times, O'Brien quickly sought physical therapy to avoid opioid painkillers.

“I have three kids, so I can't really function if I was stoned,” she said. But getting her health plan to fully cover the cost of months of physical therapy proved to be a lot harder than getting a Vicodin prescription. “I ended up spending about $40,000 out of pocket.”

While patients like O'Brien often struggle to get reimbursed by insurers for the cost of non-opioid pain treatments such as physical therapy, consumer out-of-pocket spending for opioid prescriptions has declined over the years because of increases in coverage by Medicare and health plans. According to a study published in May in Health Affairs, out-of-pocket spending on opioids (measured per 100 morphine milligram equivalents) fell nearly 80% from 2001 to 2012.

By contrast, many public and private insurers place limits on the amount of physical therapy they will pay for. Medicare Part B reimbursement, for example, maxes out at $1,960 for physical therapy unless a patient qualifies for an exception.

And it's not only consumers who have a hard time finding alternatives to opioids. Even now that the overuse of the drugs is fingered as a culprit in the overdose epidemic, providers say they struggle to get paid by insurers for alternative therapies compared with the ease of prescribing an opioid.

Therapies such as acupuncture, chiropractic care and massage, as well as more interventional therapies like epidural steroid injections for lower back pain, carry limited or no coverage by insurers.

“Insurance coverage for non-opioid therapy is just not there,” said Dr. Anita Gupta, vice chair of Drexel University College of Medicine's pain medicine division. “It's a hurdle for patients, a hurdle for physicians to get approval.”

Amid the epidemic of overdose deaths, 60% of which are related to prescription opioid abuse or misuse, physicians are trying to steer patients toward other forms of pain therapy after years of liberally prescribing drugs.

The medical community turned to opioid prescriptions to address a condition many believed had been ignored or undertreated. And the dependence on fee-for-service payments also made it easier for providers to whip out their prescription pads rather than spend the time to help patients find alternatives. But experts now say the over-reliance on opioids for chronic pain despite a lack of evidence on their efficacy and impact was misguided and has distorted the public's concept of what pain is and what it means to be treated.

Physicians are in a tough position as they encounter rising numbers of patients who have built up resistance to opioids and seek treatment while addicted or at risk of addiction.

“Oftentimes, it's when the patient has already been taking large quantities of opioids and their pain is still very much present that we're seeing these patients, and they're already dependent on these medications,” said Dr. Steve Yoon, a physiatrist at Kerlan-Jobe Orthopaedic Clinic in Los Angeles. “The first thing we have to do is manage their opioid dependence and then figure out what's the best way to treat their pain.”

Dr. Neel Mehta, medical director of Weill Cornell Medical College's Pain Medicine Center, which specializes in treating long-term pain, said many patients show up there because their doctor refuses to write them another prescription. “So we're sort of left with them expecting to get prescribed an opioid and we have to then calmly redirect that,” Mehta said. The other common profile is the patient who has been using opioids for a long time and wants to stop. “Those are the easier ones,” Mehta said.

Gupta at Drexel said the opioid crisis is leading to more complicated conversations with patients about treatment options, which often reveal physiological or emotional problems that aren't easily resolved and require long-term treatment.

The Centers for Disease Control and Prevention recently recommended doctors prescribe alternative treatments such as over-the-counter medications, cognitive behavioral therapy and exercise before resorting to opioids. Weeks later, the Joint Commission clarified its 2001 standards for pain management and treatment to stress that opioid use was neither required nor specified for treating pain.

Growing awareness of the damage the drugs have done to so many patients, families and communities appears to be changing prescribing practices. According to the National Institute on Drug Abuse, the number of opioids dispensed in U.S. pharmacies declined in 2013 to 207 million after rising steadily from 76 million in 1991 to 219 million in 2011.

Alternative strategies include physical therapy, chiropractic care and psychological counseling, as well as the use of anti-inflammatory and neuropathic medications and even vitamin supplements. The problem is that few carry the punch or, for some, the pleasure of opioids. “There is not a great advancement in the options for medication therapy,” Gupta said.

Researchers and drugmakers have not dedicated much attention to finding an effective, non-addictive drug alternative to opioids, though there are signs now of an uptick in interest.

The use of medical marijuana, meanwhile, has increased in several parts of the country. It's approved in 38 states and the District of Columbia for patients with illnesses such as cancer and HIV. But only some of those states allow the use of marijuana to relieve chronic pain.

Patients and providers are left with a lack of pharmacological options, insufficient access to alternative therapies and little knowledge among primary-care physicians about how to provide a multidisciplinary approach to pain management.

“It's easier for a prescriber to stick to their usual course of action, which is to write a prescription,” said Rick Jung, chairman and CEO of Clinicient, a technology company that works with physical therapists to measure their outcomes. “It's harder to discern exactly what the right treatment course would be for that individual's pain.”