If you’ve ever been diagnosed with chronic pain, then you know how difficult navigating your health insurance options have become. Specifically, as the opioid crisis has come into clearer view, patients say it’s harder to get treatment for pain and their options are more limited. Also, the cost of medical care is higher than many patients can afford. Since Schedule II narcotics, e.g., Oxycontin (oxycodone), morphine and Vicodin (hydrocodone), are the crux of the problem for chronic pain patients, here, we explore alternatives to opioids.
A Recap of the Opioid Crisis in the U.S.
Just to recap: In the early aughts, pharmaceutical companies dumped billions of tabs of highly addictive opioids into communities all over the country. At the same time, drug reps told doctors their meds were perfectly safe. One led to an opioid crisis that left many addicted to pain meds; the other was a blatant lie. As a result, millions of Americans found themselves hooked on drugs like oxycodone and hydrocodone.
When state lawmakers passed legislation to limit treatment with opioids, a great number of patients suddenly found themselves cut off from their prescription pain medications. According to Pew Charitable Trusts, after federal agencies suggested passing laws restricting prescribing painkillers, more than half of states complied. Later, experts reported that advice may have been taken too far.
The goal was to make it harder for just anyone to get addictive drugs to treat pain. But also, legislators wanted to hold pharmaceutical companies responsible for pushing addictive drugs and stop unethical doctors from operating pill mills. Many unintended targets got snared in the net. Suddenly, patients with pain disorders and those with diseases that cause chronic pain, like cancer, arthritis and neuropathy, were left with few good options.
Chronic Pain Patients’ Barrier to Treatment
Additional barriers to treatment cropped up for pain patients. After the implementation of Prescription Drug Monitoring Programs (PDMPs), a lot of doctors simply stopped prescribing opioids. Those who continued prescribing meds were at risk of losing their license if credibly accused of writing too many scripts. Out of an abundance of caution, many PCPs cut patients off from their medications early.
That doesn’t mean that chronic pain patients had no treatment options—though, as you’ll see, many had fewer good options. PCPs that stopped prescribing opioids did refer patients to pain specialists. But that option came with a copay that cost a lot more than a visit to the family doctor.
State requirements for opioid prescriptions
In many states, patients taking opioid medications prescribed by a pain specialist are required to see their doctor every month. They’re also subjected to random urine drug screenings. While new laws and policies aim to curtail the opioid epidemic, they’re also responsible for limiting access to alternative treatments for chronic pain. Why? Because a prescription and monthly PCP visit costs a lot less than seeing a specialist and pursuing non-medication treatments for pain disorders.
What Happens When Primary Care Physicians Stop Prescribing Opioids to Chronic Pain Patients
Here’s an example of how one patient’s treatment plan changed after their PCP in Texas stopped prescribing opioids.
The patient had been seeing their family doctor for five years for treatment of a diagnosed chronic pain disorder. State law required the patient to see their PCP every three months for pain-medication management. The annual cost of treatment came to $430 and included:
- $200 for 4 doctor appointments
- $15 for two generic opioids and one non-opioid Rx
- $50 copay for a urine drug screening
After switching to a pain disorder specialist, the annual cost of treatment came to about $1,896, including:
- 12 in-office visits at $125 per appointment
- $50 copay for 6 urine drug screenings
- $8 copay for an opioid prescription
To reduce their monthly expenses, the patient went from three medications — an extended-release opioid painkiller, a breakthrough opioid painkiller, and a non-opioid muscle relaxer — to just one monthly opioid painkiller.
Here’s something interesting about Texas: patients can get pain meds from their PCP and the state only requires one in-person doctor’s visit per quarter. However, when the patient is taking the same opioid medication, but for long-term treatment with a pain specialist, the state requires monthly in-person doctor visits. Depending on the health insurance plan, that’s a $100 increase per appointment, plus an additional eight $125 mandatory office visits per year.
Chronic Pain Disorder & the Opioid Crisis
There are several downsides to legislation that was designed to put the brakes on the opioid epidemic. The first is that it tangled pain patients up in bureaucratic red tape. Here are other ways patients were affected by policies limiting treatment with pain meds:
- After PDMPs were implemented, many PCPs stopped prescribing opioid medications long-term.
- Patients were given the option to go to a pain specialist. But the cost of treatment by a specialist can be three to five times higher.
- Many alternative treatments and devices for chronic pain cost more than taking opioid medication. For example, a weekly physical therapy appointment can cost $500 per month ($6,000 per year). A surgical procedure might be covered by insurance, but a patient has to pay for it out-of-pocket until they reach their deductible. A deductible can be hundreds or thousands of dollars, depending on the plan.
An astronomical monthly medical bill is not the only barrier to treatment for chronic pain patients. Individuals who don’t have a regular work schedule, can’t secure childcare or can’t afford it may not be able to see a specialist every month. It’s the same for patients who don’t have reliable transportation. In some states, like Texas, telehealth visits are not an option for chronic pain patients taking opioids.
And we haven’t even touched on the patients who forego health care all together because they’re drowning in medical debt. According to CNBC, “A quarter of Americans owe $10,000 or more in medical debt…half of them have health insurance.” Does anyone now wonder why many people turn to street drugs to manage their chronic pain? Those drugs are cheaper and, frankly, easier to get.
Alternatives to Opioids for Chronic Pain Patients
So what’s the solution? Public health experts say that patients researching treatment options for chronic pain disorders should consider alternatives to opioids. Fortunately, there are quite a few out there. But whether your health insurance covers these alternatives—or to what degree they’re covered—depends on what insurance you have and where you live.
Treatment options for patients with chronic pain disorders
If you have chronic pain (pain lasting at least two weeks) or have been diagnosed with a chronic pain disorder (a chronic health condition that causes pain that lasts at least two weeks), there are several treatment alternatives to opioid medications. The Affordable Care Act (ACA) requires participating health plans to offer a set of essential health benefits (see chapter 2 of Decoding Health Insurance and the Alternatives). However, plans differ in the specific type of care they offer.
Here are insurance benefits for chronic pain patients
- Mental health and substance use disorder services. Patients who have been taking pain meds for years and are abruptly cut off can use this benefit to get help managing withdrawal symptoms. Also, mental health practitioners that specialize in treating chronic pain patients can teach individuals how pain affects mood, thinking and behavior, and give them tools to cope with their condition. A therapist can cost $75 or more per session.
- Prescription drugs. Patients can take non-opioid pain relievers, nerve blockers, muscle relaxers, antidepressants and other medications to help manage their chronic pain. Prescriptions can cost about $5 to $35 per month for generic drugs.
- Rehabilitative services and devices. This benefit includes services like physical therapy, chiropractic care, injections and acupuncture. It also helps pay for devices that dull or block pain signals. Costs vary widely, depending on the health insurance plan, the patient’s location and their deductible.
- Emergency and ambulatory services. Health insurance companies do not require an approval or referral to go to an emergency room. For outpatient treatment, some patients are not required to get a referral to see a specialist. “However, if that specialist recommends an outpatient surgery or procedure (which is considered ambulatory if they don’t spend the night in the hospital), the patient will likely have to get approval or authorization ahead of time,” according to Lauren Jahnke, author of Decoding Health Insurance and the Alternatives. An ER copay can cost anywhere from a few hundred dollars to $5,000 or more.
Check Out Decoding Health Insurance and the Alternatives
The book Decoding Health Insurance and the Alternatives provides important information about health insurance plans. It’s in every chronic pain patient’s best interest to consider all of the different health insurance plans available before choosing the one that, on its face, may seem like the best deal. Here are a few questions you can answer before deciding which health insurance plan is best for you:
- Can I see my PCP or do I need to see a specialist for pain?
- How much does it cost to see a specialist?
- How often will I be required to see the specialist for my condition?
- How much will I have to pay for prescription medications?
- How much will I be required to pay for devices and procedures?
- How much is the deductible?
- What other out-of-pocket costs will I be responsible for (i.e., random urine drug screenings)?
At DHI, our goal is to help you understand your health insurance options. You work hard to pay for your health insurance, so why not understand all the ways to get your health insurance to work for you? If you like this blog post and want to see all of our health-insurance news and updates, subscribe to the DHI newsletter right now.