U-M researchers examine barriers to primary and specialty pain care for patients taking opioids for chronic pain and outline a series of policy considerations to improve access.
Improving Access to Primary and Pain Care for Patients Taking Opioids for Chronic Pain in Michigan
Drug-related overdoses continue to climb in the U.S. Preliminary data show that overdose deaths climbed to over 93,000 in 2020, up from 70,000 in 2019.1 To combat the ongoing opioid crisis, state and federal agencies and health systems across the country instituted policies to reduce inappropriate opioid prescribing.
Though these policies have been shown to reduce prescribing, stakeholders are concerned that policies to reduce prescribing may unintentionally restrict care for an estimated five to eight million adults in the U.S. who are receiving long-term opioid therapy for chronic pain.2,3 As physicians reduce or stop opioid prescriptions, and some retire, the “forgotten population” of patients who have developed physical dependence on opioids can struggle to find new providers willing to treat them.4
In addition, national working groups have found that existing reimbursement models, a lack of care coordination, provider stigma around opioid use, and racial inequities affect access to effective pain care and patient outcomes. National guidelines recommend that pain care be multimodal, involving a combination of medications, physical therapies, interventional procedures, and behavioral health approaches.3,5
For patients receiving opioids for chronic pain, barriers to both primary and specialty pain care could lead to uncontrolled pain and other unintended consequences, such as conversion to illicit substances or poor management of mental and physical comorbidities.
Takeaways from our research
A University of Michigan research team studies access to evidence-based treatments for patients with chronic pain who are taking prescription opioids. The team’s findings include:
Many patients taking opioids for chronic pain are likely not receiving the care they need due to barriers to accessing primary care and specialized pain care services.
In audit studies in which researchers called primary care clinics simulating as patients taking opioids for chronic pain:7,8
- Over 40% of clinics in Michigan and nationally were unwilling to accept new patients taking opioids for chronic pain.
- Acceptance rates did not differ by insurance type.
Through qualitative interviews with clinicians to better understand barriers to primary care access, they reported factors such as:9
- administrative burdens related to managing prescribed opioids
- fear of liability
- lack of reimbursement for multimodal care and coordination between providers
- stigma of opioid use
- poor availability of effective non-opioid treatments
Patients also experienced barriers in access to pain clinics and effective, multimodal pain care. In an audit study of pain clinics in Michigan:10
- 15 respondents: Many clients, especially in rural areas, had inadequate access to the internet or internet-connected devices and persistent barriers to in-person care.
- 48% did not accept Medicaid.
- 51% required a referral for care, which may be difficult for patients who experience challenges in accessing primary care.
- 90% did not offer multimodal chronic pain treatment.
How can stakeholders in Michigan improve access to care for patients with chronic pain on prescription opioids?
The U-M research team convened a panel of 24 experts from across Michigan to discuss policies, interventions, or research agendas that could potentially improve access to care. The expert panel represented a broad range of perspectives, including policymakers, insurers, providers, patient advocates, and researchers. The group met twice between September 2020 and January 2021, and provided multiple rounds of feedback between meetings.
The panel generated the following policy options and opportunities, grouped by theme:
Develop new care models to better support patients taking opioids for chronic pain
- Create a collaborative care model expanding on the existing Michigan Medicaid Health Home6 to include patients with chronic pain.
- Establish reimbursement models for chronic pain to provide appropriate compensation for all care providers, such as psychologists and physical therapists, who treat and manage patients with complex pain.
- Improve dissemination of evidence related to multimodal and non-pharmacological treatments for pain to inform insurance coverage.
Enhance provider training to strengthen chronic pain management, encourage patient-centered care, and reduce stigma
- Make providers aware of how Michigan’s Prescription Drug Monitoring Program (PDMP) data is used in investigating and disciplining providers.
- Deliver an educational curriculum that explains the continuum between addiction and physical dependency on long-term opioid therapy to all personnel who interact with patients to encourage patient-centered care and reduce stigma.
- Improve health provider education on chronic pain and multimodal and non-pharmacological therapies, both in health professional schools and continuing medical education.
- Train members of the clinical team, such as social workers, to help address biopsychosocial factors and ongoing management of chronic pain treatment.
Implement practices to address racial biases and inequities
- Evaluate and describe where individuals belonging to minority racial and ethnic groups prefer to receive health-related information and which community institutions they look to for support in healthcare decisions.
- Implement standardized pain management protocols that include mandatory reporting to provide objective data on pain management across races and ethnicities.
- Increase recruitment and retention of providers from underrepresented racial and ethnic minorities across all clinical roles, including by providing appropriate financial compensation and incentives if practicing in under-resourced communities.
- Develop implicit bias training to improve patient-provider communication around pain management.
1 Provisional Drug Overdose Death Counts. Ahmad FB, Rossen LM, Sutton P. National Center for Health Statistics. 2021. Accessed July 20, 2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
2 Opioid Prescribing in the United States Before and After the Centers for Disease Control and Prevention’s 2016 Opioid Guideline. Bohnert ASB, Guy GP, Losby JL. Ann Intern Med. 2018;169(6):367-375. PMID: 30167651. doi:10.7326/M18-1243.
3 National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Reuben DB, Alvanzo AA, Ashikaga T, et al. Ann Intern Med. 2015;162(4):295-300. PMID: 25581341. doi:10.7326/M14-2775.
4 The Opioid Crisis and the Need for Compassion in Pain Management. Rothstein MA. Am J Public Health. 2017;107(8):1253-1254. PMID: 28700305. doi:10.2105/AJPH.2017.303906.
5 Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. U.S. Department of Health and Human Services. 2019. Accessed September 16, 2020. https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html.
6 Opioid Health Home. Michigan Department of Health and Human Services. Accessed April 16, 2021. https://www.michigan.gov/mdhhs/0,5885,7-339-71547_4860_87523---,00.html.
OUR PUBLISHED RESEARCH
7 Access to Primary Care Clinics for Patients with Chronic Pain Receiving Opioids. Lagisetty PA, Healy N, Garpestad C, et al. JAMA Network Open. 2019;2(7):e196928. PMID: 31298712. doi:10.1001/jamanetworkopen.2019.6928.
8 Assessing Reasons for Decreased Primary Care Access for Individuals on Prescribed Opioids: An Audit Study. Lagisetty P, Macleod C, Thomas J, et al. Pain. 2021 May 1;162(5):1379-1386. PMID: 33230009. doi:10.1097/j.pain.0000000000002145.
9 Opioid Policy and Chronic Pain Treatment Access Experiences: A Multi-Stakeholder Qualitative Analysis and Conceptual Model. Slat S, Yaganti A, Thomas J, et al. J Pain Res. 2021;14:1161-1169. PMID: 33948090. doi:10.2147/JPR.S282228.
10 Access to Multimodal Pain Management for Patients with Chronic Pain: An Audit Study. Lagisetty P, Slat S, Thomas J, et al. J Gen Intern Med. 2021 Mar;36(3):818-820. PMID: 32378013. doi:10.1007/s11606-020-05866-3.
11 Improving Access to Primary and Pain Care for Patients Taking Opioids for Chronic Pain in Michigan: Recommendations from an Expert Panel. Lagisetty P, Kehne A, Thomas J, et al. 2021. doi:10.7302/1699.
Pooja Lagisetty, M.D., M.Sc.
Department of Internal Medicine, University of Michigan
For a list of contributing authors, please view the full report.
This project was funded by the Michigan Health Endowment Fund. The research team is deeply grateful to the panelists for their thoughtful, sustained engagement and to our facilitators for leading such rich discussions.
Pooja Lagisetty, M.D., M.Sc., was a recipient of the 2020 IHPI Policy Impact Award for her research on expanding access to evidence-based treatments for individuals with chronic pain and opioid use disorders, which has impacted national policy on barriers to opioid addiction treatment.
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