Affordable Care Act, Drug Abuse, and Pain Management

Savage: Affordable Care Act Offers Opportunity to Combat Pain and Drug Abuse

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• By Seddon R. Savage
• April 5, 2013, 6:53 p.m.

There is a growing national debate about two important life and death issues: the abuse of powerful pain medications and the treatment of chronic pain. The Centers for Disease Control and Prevention has classified prescription drug abuse as a deadly epidemic and the White House Office on National Drug Policy has declared the crisis to be a top public health priority. Meanwhile, a landmark 2011 Institute of Medicine report highlighted the challenges of pain in our aging society — a problem affecting 100 million people at a cost to the U.S. economy of about $600 billion a year.

To address these twin crises, it is critical that Congress fund programs within the Affordable Care Act that provide powerful opportunities to improve care of persons with pain and with substance abuse disorders. These two challenges intersect because many powerful pain medications, such as morphine and oxycodone (known as opioids), that are used to relieve pain for millions of Americans are also misused by others trying to get high or relieve distress. Such misuse can result in addiction or death.

But what has been missing from the public discussion so far is the fundamental reality that better pain treatment will reduce abuse of prescription opioids. To better treat pain, Congress must maintain funding for medical research despite budget proposals that would put it on the chopping block. If we do not find new ways to improve treatment of chronic pain, prescription drug abuse will continue to rise.

The simple equation is this: More pills used to treat pain equals more pills available for misuse. There is certainly room to improve opioid prescribing practices by doctors, and we can work to reduce diversion of opioid medications by raising public awareness and encouraging people to lock up their medications and destroy leftover pills. But until we as a society work to advance pain treatment options and support payment for more comprehensive pain management, doctors will use opioids to relieve suffering, and we will be challenged by prescription opioid abuse.

Federal agencies are scrambling to address prescription drug abuse and earlier this month a bipartisan group of eight senators called for a Government Accountability Office report to better coordinate interagency efforts. Drug Enforcement Agency-sponsored drug take-back days have made thousands of tons of unused drugs unavailable for abuse. The Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, and the Food and Drug Administration have all launched innovative education initiatives to improve prescribing. This month, an FDA panel recommended increased restrictions on one opioid drug and another panel heard testimony on a controversial proposal to re-label all opioids to limit their use in chronic pain.

A critical piece of the solution to reducing prescription opioid abuse, however, lies in improving options for treatment of both pain and addiction disorders.

Chronic pain is often a complex condition in which biological, psychological and social issues intertwine to amplify suffering and disability. While private and government insurance programs usually pay for medications and injections that can relieve the symptom of pain, it is often impossible to get adequate coverage for clinician time to fully evaluate the complex causes of persistent pain. Further, it’s hard to get support to coordinate and pay for adequate counseling, physical therapy, complementary treatments and other approaches that may empower patients in long-term recovery. If we improve care of chronic pain, we will in turn need fewer prescriptions and see less diversion and abuse.

The rollout of the Affordable Care Act is a huge opportunity to both reduce prescription drug abuse and improve the care of pain. The ACA names essential benefits that must be included in new programs, such as state insurance exchanges and Medicaid expansions that will serve as models for all insurers. These include a requirement for treatment of mental health and substance-use disorders in parity with other medical conditions that can potentially expand access to care for millions who need it.

In addition there are provisions to improve management of chronic diseases through better support for care coordination and doctor-patient visits, and helping patients better manage their own health. These should be extended to the chronic conditions of pain and addiction. Such benefits will reduce long-term health care costs by reducing more expensive complications of poorly managed illness.

Importantly, the Affordable Care Act also creates an Interagency Pain Research Coordinating Committee intended to enhance pain research efforts and collaboration. Despite the fact that pain is the most common reason people consult doctors, research focused on pain currently makes up less than 1 percent of the research budget of the National Institutes of Health.

Reducing pain and reducing drug abuse are not, as commonly thought, at odds. Members of Congress can fight prescription drug abuse and pain together by ensuring that the powerful opportunities afforded by the ACA to advance pain research and improve care of persons with chronic pain and with addiction disorders are fully realized in its implementation.

Dr. Seddon R. Savage is director of the Dartmouth Center on Addiction, Recovery and Education, teaches at Dartmouth’s Geisel School of Medicine and is the immediate past president of the American Pain Society.