The following editorial by local claimant attorney Gregory J. Hubachek and D. Kirkhoff Brainard is the second of a three-part series on the opioid crisis. Below, Hubachek lays out his ideas for a modern approach to opioid drugs, including the concept of “integrative medicine.” Read part one of this series here.
As lawmakers and public health officials across the nation grappled with the ongoing surge of opioid deaths in 2017, multiple states either passed new opioid-related legislation or updated existing laws.
Unfortunately for injured workers (and other patients suffering with severe pain), many of the new laws merely deny patients access to prescription pain medications while failing to provide viable alternative treatments.
The insurance industry has certainly recognized the opioid crisis as a golden opportunity to consolidate financial gains made over the past several years at the expense of injured workers. Many of the opioid-related reforms affecting workers’ compensation claimants align with the core values of insurers and employers: cost containment and risk reduction.
Louisiana has consistently ranked near the top of state rankings for the amount of prescription opioids consumed. In this series, we will look at how legislation enacted in Louisiana and other states impacts the health and safety of America’s injured workers. And we will propose an evidence-based solution for Louisiana that will save lives and reduce both the human and economic impact of opioid overdoses.
By the numbers
The statistics continue to shock.
Opioid drug overdoses now claim more American lives than guns and auto accidents. The CDC says 91 Americans die every day from an opioid overdose, a number that is expected to rise again this year based on data from the first three quarters of 2016.
Although prescribing of opioid painkillers appears to have declined from its 2014 peak, public health officials say the widespread availability of heroin and the synthetic opioid fentanyl are fueling a trend that has seen overdose deaths quadruple since 1999. 
Hospital and emergency room visits due to opioid overdoses have doubled since 2005; Americans now make 3,500 opioid-related hospital visits each day. 
Faced with overflowing emergency rooms and law enforcement budgets strained to the breaking point, the governors of Arizona, Florida and Maryland all issued opioid-related state of emergency declarations in 2017. 
In March, President Trump’s opioid crisis commission compared the opioid epidemic to the 9/11 terror attacks and urged the President to declare a national state of emergency. “The opioid epidemic we are facing is unparalleled,” the commissioners wrote in their initial report. “America is enduring a death toll equal to September 11th every three weeks.” 
President Trump in April approved $485 million in state grants authorized under the 21st Century Cures Act.  And the President’s 2018 budget proposal includes a request of $12 billion for drug treatment and prevention programs. However, little of the funding made available to states under these federal appropriations appears likely to trickle down to injured workers and other patients suffering from chronic pain. 
Legislative reform at the state level falls broadly under two categories: adherence to the CDC Opioid Prescribing Guidelines, and adoption of closed pharmacy formularies.
In 2016, I noted that the proposed CDC Opioid Prescribing Guideline was already changing the way physicians treated their chronic pain patients and predicted it would not take long for these voluntary guidelines to become de facto law.  As expected, several states – Massachusetts, Maine, Connecticut, New York and Rhode Island – immediately adopted the CDC’s seven-day limit on first time prescriptions. 
In October, Montana became the latest state to adopt the Official Disability Guidelines (ODG). The ODG is a highly restrictive ‘closed pharmacy formulary’ – a very limited list of medications that physicians are allowed to prescribe – that has been used to successfully slash the cost of benefits for injured workers in Texas, Oklahoma, Arizona and Washington.
At least ten other states are now considering adopting the ODG formulary or similar closed formularies as a part of their opioid crisis response strategy.
The Louisiana legislature has consistently voted down attempts to implement a closed formulary. In June, Governor John Bel Edwards signed Louisiana Act 82, which follows the CDC guidelines in implementing a seven-day limit on first-time prescriptions of opioids for acute pain. However, the new law also gives doctors the ability to override the CDC limit by including “standardized notations in compliance with current code requirements” in the patient’s record. 
In 2017, legislation was also passed in Louisiana which will mandate physician participation in multi-state prescription medication monitoring programs (i.e., PDMPs) and enhanced physician education requirements relative to opioid medications. In this way, the leadership of Governor Edwards has already manifested itself in broad, positive regulation of opioid administration.
Integrative medicine: a consensus solution
The advent of cloud-based computing and advanced data analytics is driving a major shift from fee-for-services to fee-for-performance across the entire healthcare industry.
Contrary to the “evidence-based medicine” approach touted by insurer-backed research groups and exemplified in the CDC opioid guidelines, the data shows that health outcomes improve when providers treat the patient as a whole person. This approach to healthcare and wellness is broadly described as integrative medicine.
The CDC guidelines specify that opioids should not be considered “first-line or routine therapy for chronic pain.” Although the CDC guidelines stop short of embracing “integrative medicine,” they do recommend alternative therapies – including physical therapy, cognitive behavioral therapy (CBT), and psychological therapy – in addition to, or as a substitute for, opioid medications.
Non-pharmacologic alternative therapies reduce the injured employee’s reliance upon opioid medications at the outset of treatment and, subsequently, assist in the reduction of dosage and duration of opioid medications at the conclusion of treatment. In this way, non-pharmacologic alternative therapies are useful throughout the treatment plan.
Other federal agencies – including the National Institutes of Health, Department of Defense, and Veterans Administration – have approved a broader list of alternative therapies. These include chiropractic care, acupuncture, massage, biofeedback, and yoga.
Integrative medicine is also the solution favored by many non-governmental organizations including the American Institute of Pain Management (AIPM) and The Joint Commission, which evaluates and accredits almost 90 percent of U.S. hospitals.
“We know — and it’s been confirmed by the Institute of Medicine and in the recently-issued National Pain Strategy — that pain is a complex biopsychosocial phenomenon, and that an integrative approach is the only safe and sane way to care for people with pain,” says AIPM director Bob Twillman. “There is no cookbook for pain care, and one size doesn’t even fit most, so we need to use an integrative approach that permits maximum flexibility in providing care.” 
Effective Jan. 1, 2018, The Joint Commission will require accredited hospitals to “provide nonpharmacologic pain treatment modalities” as a necessary performance. The commission’s pain management standards state:
“Both pharmacologic and nonpharmacologic strategies have a role in the management of pain … strategies may include the following: Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavior therapy.” 
Despite the evidence-based merit of alternative therapies in treating opioid patients, the CDC guidelines note that:
“These therapies are not always or fully covered by insurance, and access and cost can be barriers for patients.” 
AIPM director Twillman names access to alternative therapies as the biggest challenge physicians face in dealing with the pain management issues that are at the core of the opioid epidemic:
“Access to integrative non-pharmacological treatments such as acupuncture, massage therapy, biofeedback and others has never been good because insurance reimbursement is poor, causing people with pain to have to pay out of pocket for these treatments — something many of them can’t do. Adjunctive treatments such as physical therapy and behavioral health care might be more readily available, but they also are subject to inadequate insurance coverage that makes true access less than optimal.” 
Compared to many states, Louisiana is taking a progressive approach to pain management in the workers’ compensation population. The Louisiana Commission on Preventing Opioid Abuse (LCPOA) was established by the state legislature in 2016 to explore best practices for reducing the human and economic costs of opioid addiction. In its final report, issued April 1, 2017, the commission recommends alternative therapies, psychotherapy, and CBT as preferred treatments for managing chronic pain. 
The Louisiana Workers’ Compensation Medical Treatment Guidelines (MTG) note that: “Interdisciplinary rehabilitation programs are the gold standard of treatment for individuals with chronic pain.” 
The MTG endorses the use of acupuncture, chiropractic treatment, osteopathic manipulation and physical therapy for initial, conservative care and treatment of chronic pain. While all of these recommendations are laudable, they are also highly unlikely to amount to any substantive change as long as access to them continues to be hindered and restricted by insurers and employers who would rather not pay for them.
 Centers for Disease Control and Prevention, “Opioid overdose: Understanding the epidemic,” accessed October 5, 2017, https://www.cdc.gov/drugoverdose/epidemic/index.html.
 Joel Achenbach and Dan Keating, “In just one year, nearly 1.3 million Americans needed hospital care for opioid-related issues,” The Washington Post, June 20, 2017, https://www.washingtonpost.com/news/to-your-health/wp/2017/06/20/in-just-one-year-nearly-1-3-million-americans-needed-hospital-care-for-opioid-related-issues/.
 Kimberly Leonard, “Arizona governor declares state of emergency over opioid crisis,” Business Insider, June 5, 2017, http://www.businessinsider.com/arizona-opioid-crisis-state-of-emergency-2017-6.
 Commission on Combating Drug Addiction and Abuse, “Commission Interim Report,” Office of National Drug Control Policy, March 29, 2017, https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf.
 U.S. Department of Health & Human Services, “Trump Administration awards grants to states to combat opioid crisis,” April 19, 2017, https://www.hhs.gov/about/news/2017/04/19/trump-administration-awards-grants-states-combat-opioid-crisis.html.
 The bulk of the state grants authorized under the 21st Century Cures Act is earmarked for drug prevention efforts by community-based coalitions and medication-assisted treatment for overdose victims. Comprehensive Addiction and Recovery Act, S.524-114 (2016), https://www.congress.gov/bill/114th-congress/senate-bill/524/text.
 Gregory J. Hubachek, “A Bipartisan Prescription” for Louisiana’s Opioid Crisis: Part 2,” Louisiana Comp Blog, April 1, 2016, https://compblog.com/guest-post-gregory-j-hubachek-on-a-bipartisan-prescription-for-louisianas-opioid-crisis-part-2/
 Christine Vestal, “In States, Some Resistance to New Opioid Limits,” Stateline, The PEW Charitable Trust, June 28, 2016, http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/06/28/in-states-some-resistance-to-new-opioid-limits.
 Louisiana Administrative Code, Title 46, “Professional And Occupational Standards,” Part XLV, “Medical Professions,” Subpart 3, Chapter 69, Subchapter B, “Medications Used in the Treatment of Non-Cancer-Related Chronic or Intractable Pain,” Section 6921, “Use of Controlled Substances, Limitations,”
 Nicole Stagg, “Calling for an Integrative Approach to Pain Management,” AIPM News, May 23, 2017, http://www.integrativepainmanagement.org/news/346529/Calling-for-an-Integrative-Approach-to-Pain-Management.htm
 Dynamic Chiropractic, “Coming Soon to a Hospital Near You,” Vol. 5, 11, September 1, 2017, http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=57998.
 CDC, “Guideline,” 12.
 Stagg, “Integrative Approach.”
 Louisiana Commission on Preventing Opioid Abuse, “The Opioid Epidemic: Evidence-Based Strategies Legislative Report,” April 2017, p. 32.
 Louisiana Workers’ Compensation Medical Treatment Guidelines, “§2131.5 Therapeutic Procedures – Non-Operative,” 2009, http://www.laworks.net/WorkersComp/OWC_MedicalGuidelines.asp.
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