Are We Doing All We Can to Stop the Opioid Crisis?
The opioid crisis has risen to the level of national emergency. Yet, at a time when nearly 100 Americans are dying every day from opioid overdoses, these medications continue to be prescribed at an alarmingly high rate. How is it that our health care system, which is designed to care for patients, has inadvertently contributed to one of the worst health epidemics in history?
Regrettably, the answer is relatively simple. Opioids are easy to prescribe, and insurance companies consistently reimburse for them. So for a patient who complains of pain, opioids are an obvious short-term solution -- even while the long-term risks of addiction and abuse loom on the horizon.
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We Must Be Open to New Approaches
The burden of addressing the opioid crisis cannot be placed only on doctors and their prescription pads. As an industry, we must develop new technologies that offer patients effective non-opioid treatments for pain. As a biomedical engineer whose career has been spent helping the nation's hospitals evaluate and implement new technologies -- including for pain management-- I know this is doable. But it won't be easy. Alternatives must compete on safety, efficacy and cost if they are to become acceptable for hospitals and doctors to recommend.
The good news is that many technology-based alternatives to opioids are already available. Spinal cord stimulation is an underutilized pain management alternative for patients struggling with chronic pain. This implanted pacemaker-like device is shown to effectively manage pain while significantly reducing opioid use. Regional pain pumps are a promising alternative for acute pain. They deliver local, non-opioid anesthetics directly to nerves feeding the surgical site, and can provide significant pain relief for several days after a procedure. These types of technologies enable what is known as multi-modal pain control, promoting a combination of devices and analgesics that have a low risk of addiction, such as ibuprofen, to manage pain -- thus reserving opioids as a last resort.
But, weighing the value of these alternatives requires a shift in thinking that prioritizes investment in opioid avoidance. Today, these alternatives are often viewed as financially unviable or cumbersome to implement. And newer technologies that show promising initial results face even greater barriers. When not given a choice, clinicians have no other option but opioids. We must now create the pathways that facilitate alternative treatments.
Accomplishing this, however, will require changes at every level of the system.
Think Outside the Box
In most industries, you might be rewarded for thinking outside the box; health care is not typically one of them. The U.S. health care system favors a conservative approach to treatment and reimbursement policy. To a degree, this design is intentional. It creates safeguards that protect patients and prevent runaway costs.
Unfortunately, we don't have the luxury of time to await clinical results developed in the standard way as our nation comes to grips with the opioid crisis. The cumbersome processes of the traditional system are not agile enough to prevent an estimated half a million deaths in the coming decade due to opioid addiction. Therefore, we need a new paradigm, built around speed and innovation to fast-track emerging technologies into mainstream pain management.
Do the Research
When it comes to patient care, the burden of proof falls upon the new. Innovation, however, is predicated on rapid change. To reconcile the two, we need to employ a streamlined, focused approach to creating and synthesizing the clinical evidence used to inform health care decisions. Important factors in the innovation decision include anticipated clinical benefit, patient risk and costs. The right combination of these factors allow for the rapid adoption of innovation.
Early adopters of new technologies have an imperative and responsibility to conduct clinical trials and publish their findings so that evidence can be synthesized and worthwhile technologies identified. Without research into cost effectiveness and clinical utility, even the most promising innovations may languish or fail to become part of mainstream care. There is a lesson here for manufacturers as well, to support and develop early evidence for their technologies.
Beyond helping hospitals and providers adopt alternatives, this research also helps communicate value to insurers. For instance, even if a spinal cord stimulator is more expensive upfront, research may show how it prevents other downstream resource utilization, reduces the risk of substance abuse and its associated costs, or saves costs over the long-term. From a holistic viewpoint, it may be in the insurer's best interest to reimburse for a more costly regional pain pump for a patient who has experienced opioid addiction in the past or who is at high risk for addiction. The focus here should be on buying outcomes, not devices. As we transition to a value-based reimbursement system, this concept holds even greater promise.
Further, government agencies like the Centers for Medicare & Medicaid Services can promote innovation by providing reimbursement mechanisms for new treatments that curb opioid use. CMS policies such as coverage with evidence development and early creation of national coverage determinations are a step in this direction. The U.S. Food and Drug Administration, which is also ramping up efforts to contain the opioid crisis, can benefit providers by expediting approval for new technologies. The 21st Century Cures Act has provisions to empower the FDA in this regard. Increased National Institutes of Health funding for innovative technology research should also be provided to address the opioid epidemic.
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Change the Culture
Last year, St. Joseph's Regional Medical Center's emergency department reportedly decreased opioid use by an astounding 38 percent. Instead of using opioids as the first option, they offer local anesthetics, pain pumps and other alternatives to patients to help them manage pain (i.e., a multi-modal approach). This would not have been possible, however, without a profound cultural shift.
In settings where opioid prescriptions are commonplace -- like emergency care -- it can be difficult to step back and rethink pain management. This is especially true when medical staff may have less awareness of pain management alternatives and how to implement them. The change can only come about when new policies are created and leadership, physicians, nurses and other staff all become aligned in the new mindset.
This may require more hospitals to staff up with pain management specialists who have the formal training and experience to guide providers through a cultural transition. But we shouldn't wait for this. Sometimes it only takes a single outspoken champion within a department to convince everyone to view opioids as the alternative rather than the go-to treatment.
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Train the Next Generation
As we look to the future, we should also take concrete steps to provide a medical curriculum with more emphasis on pain management, multi-modal treatments and opioid abuse prevention. A 2011 study in The Journal of Pain found that U.S. medical schools spend an average of nine hours on pain and its management -- a paltry 0.03 percent of total curriculum hours. Boosting pain education programs is undoubtedly needed and may create the future innovators to solve our problems.
Given the gravity of our current crisis, as well as the high risk of addiction, we cannot afford to continue down the current path. It will take nothing less than reorienting our entire system around innovation to accelerate the use of opioid alternatives. Every day we delay is an opportunity lost to save dozens of lives.
Joe Cummings, PhD leads the Technology Assessment Program for hospital members at Vizient, Inc.
Joe Cummings, PhD leads the Technology Assessment Program for hospital members at Vizient, Inc.
