Proper Incentives for Proper Pain Treatment

I was speaking recently at a national medical conference when the speaker preceding me talked about having to manage his patients’ pain before tending to their other chronic diseases. This comment may seem odd, but the reality is that pain, especially chronic pain, can be so disabling that a patient will seek care through any means necessary, including going to the emergency room. And when a patient’s pain goes unmanaged, that patient is more likely to stop seeing their doctor altogether, thus forgoing treatment for other chronic disease like hypertension or diabetes.

In the United States, one in three people suffer from some form of pain, and approximately $650 billion is spent annually on medical treatment and lost productivity due to pain. Fortunately, awareness of the need to appropriately treat pain has grown in the past decade. For example, in 2001 California passed legislation requiring physicians and surgeons licensed in California to complete a mandatory continuing medical education course on pain management and the treatment of terminally ill and dying patients. More recently, in 2011 the Institute of Medicine issued a report summarizing “a blueprint for action in transforming prevention, care, education, and research, with the goal of providing relief for people with pain in America.”

At the same time, the use of opioids to manage pain has increased dramatically. But because of the addictive nature of opioids, and their frequent misuse and abuse, mortality has unfortunately increased as well. Use of other classes of pain medicines has also increased, but not to the level of opioids.

What’s behind the exponential increase in opioid prescribing for chronic pain, which requires different therapies for distinct pain syndromes?  One explanation for the increase may be because opioids are an effective treatment for chronic pain and can play a role in pain management with judicious use and appropriate monitoring. However, data on longterm effectiveness is not sufficient to explain their dramatic rise in use. In fact, in certain types of pain, such as neuropathic pain, longterm use of opioids may actually worsen the outcome.

Perhaps the answer lies in payer policies that make it difficult for a physician to prescribe branded medicines, even when they are medically appropriate for patients, and that encourage patients to take generics, even when they may not be medically appropriate and present higher safety risks. The majority of opioids used are somewhat lower-cost generics. So for the past decade, since payers weren’t paying for branded anti-inflammatory and neuropathic pain treatments, doctors were prescribing generic opioids instead. As expected, opioids preferred by payers were increasingly prescribed, and that’s why greater than 40 percent of first line treatment for diabetic peripheral neuropathy is with an opioid. Payers forgot the principle of unintended consequences, which we must deal with now.

In an effort to stem the tide of opioid abuse, the FDA, law enforcement officials and other parties requested that the pharmaceutical industry develop abuse deterrent opioids (ADO) – opioids that cannot be manipulated by chewing, snorting or injecting, making them more difficult to abuse. Unfortunately, payers are once again circling the wagons. They are vilifying the new technology because they claim it lacks the promise of reducing abuse. The truth is that based on published literature, ADOs do reduce abuse by 20-40 percent upon introduction into the marketplace. But it is also true that the reduction in abuse plateaus over time and that some patients may move back to non-abuse deterrent opioids or to narcotics because they are still accessible. This is why we must strive to ensure that all opioids are abuse-deterrent, thus reducing the chances of the patient trading an abuse deterrent opioid for a non-ADO formulation. It is important to remember that over 70 percent of abusers obtain opioids from family and friends who have them due to a legitimate need.

If one follows the logic of payers, we should remove all seat belts from motor vehicles since people still die when wearing them during accidents. ADOs should be part of a comprehensive program to reduce opioid abuse in the U.S. Ultimately, the concern from payers is all about the increase in drug costs. Payers are ignoring the fact that appropriate use of ADOs actually reduces overall healthcare costs. In fact, the first ADO to the market reduced overall health care costs to the tune of $430 million annually. As a society, it is important to give providers the tools they need to safely and effectively treat patients who are in pain. Instead of maligning new technologies that are being developed in an effort to mitigate a national crisis, payers can become part of the solution by removing artificial barriers to access which may promote inappropriate treatment of patients.

Robert Popovian is the senior director of U.S. government relations at Pfizer Pharmaceuticals.