U-M experts examine barriers, develop roadmap to improve health care access for patients taking opioids for chronic pain

Recent state and federal policies have focused on reducing inappropriate opioid prescriptions to combat the ongoing epidemic. However, such policies may unintentionally restrict care for millions of Americans who receive long-term opioid therapy for chronic pain.

A new report, summarizing findings from a series of studies by a University of Michigan team conducted over the past couple of years, shows that many patients taking opioids for chronic pain are likely not receiving the care they need due to barriers to accessing both primary care and specialty pain care services. 

The researchers conducted audit studies in which they called providers throughout Michigan and across the United States posing as prospective patients taking prescription opioids for patients. More than 40% of primary care clinics in Michigan and nationally were unwilling to accept new patients with opioid prescriptions, and acceptance rates did not differ by insurance type. They also found that over half of pain clinics in Michigan require a referral from a primary care physician to treat a new patient, further expanding barriers to pain-related treatment for this patient population.

In follow-up interviews, clinicians listed various reasons for not accepting patients with active opioid prescriptions, including administrative burdens related to managing opioids, fear of liability, lack of reimbursement from insurance companies, and stigma of opioid use. 

“As more policies are implemented to reduce opioid prescribing, providers may be increasingly hesitant to accept new patients who have active opioid prescriptions due to increased administrative burden when prescribing and also fears around litigation,” says senior author Pooja Lagisetty, M.D., M.Sc., assistant professor of internal medicine at Michigan Medicine and a researcher at the U-M Institute for Healthcare Policy & Innovation (IHPI). “It is important for health care providers and policymakers to find the balance between avoiding overprescribing and restricting access to opioids to the point that it leads to uncontrolled pain and other unintended consequences for patients who depend on them.” 

Even when patients taking opioids were able to access pain care, they were often unable to receive the treatment needed to address the complexity of their conditions. The team found that 90% of pain clinics did not offer effective, multimodal treatment, which combines medications, interventional procedures, and behavioral health approaches to treat chronic pain. 

“Evidence consistently shows that treating chronic pain effectively requires a comprehensive approach that goes beyond medications and also addresses other physical and behavioral treatments tailored to individual patient needs, but our research found that the majority of patients aren’t receiving such treatment.”

Patients on long-term opioid therapy may also not receive adequate care when providers begin gradually reducing their dosage to eventually take them off. In a related JAMA editorial, Lagisetty and co-authors, Amy Bohnert, Ph.D., M.H.S., associate professor of anesthesiology at Michigan Medicine, and Marc Larochelle, M.D., M.P.H., of Boston University School of Medicine, discuss evidence by Agnoli, et al showing an association between opioid dose tapering and increased risk of overdose and mental health crises among patients prescribed long-term, high-dose opioid therapy. The authors suggest that current policies and incentives focused on reducing opioid prescriptions discourage clinicians from providing the time and level of patient-centered care necessary to minimize risks when tapering opioids. 

To identify ways to improve access to care, effective treatment and dose tapering for this patient population, Lagisetty and her research team convened a panel of Michigan policymakers, insurers, providers, patient advocates, and researchers with opioid expertise to discuss policy options and interventions. The expert panel generated a list of 11 policy considerations focused on developing new care models to better support patients, changing reimbursement structures to support pain treatment,  enhancing providers’ chronic pain management training, and implementing practices to address racial biases and inequities. 

 “There are so many structural barriers to providing high-quality care for individuals with chronic pain,” explains Adrianne Kehne, co-author of the report and a researcher in the Division of General Medicine at Michigan Medicine. “The wide range of expertise on our panel and the resulting recommendations highlight the interrelated complexities of this issue. It is difficult to address racial biases and inequities without enhancing training. In addition, we cannot change care models without changing reimbursement practices.”

Lagisetty adds, “Our recommendations offer a road map for key stakeholders to start to make a positive difference in providing non-stigmatizing patient-centered care for the millions of Americans on long-term opioid therapy for chronic pain.” 

●    Read the policy brief  >
●    View the full report with findings from the expert panel discussions > 
●    Related: JAMA editorial on opioid tapering practices