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Join Amy Baxter, a clinical associate professor of emergency medicine. We’ll delve into the opioid crisis, the misconceptions surrounding pain management, and the barriers that hinder effective pain relief in health care. Amy will share her expertise and insights on these critical topics, shedding light on the complexities of pain, pharmaceutical bias, and coverage policies.

Amy Baxter is a clinical associate professor of emergency medicine at Augusta University, CEO, Pain Care Labs, and can be reached on Twitter @AmyBaxterMD.

She discusses the KevinMD article, “The preference for insurance coverage of opioids over non-pharmaceutical options explained.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Amy Baxter. She’s an emergency physician, she’s the CEO of Pain Care Labs. Today’s KevinMD article is titled “The preference for insurance coverage of opioids over non-pharmaceutical options explained.” Amy, welcome back to the show.

Amy Baxter: Always good to be here, thanks for having me.

Kevin Pho: So go to KevinMD.com/podcast, you can search for Amy’s past episodes and hear her story, but today let’s get straight into this KevinMD article, “The preference for insurance coverage of opioids over non-pharmaceutical options explained.” Tell us how this article came together.

Amy Baxter: Well, I have been interested in why we have gone toward opioids, and really toward pharma, so convincingly in this country. Other countries, when we go to visit our friends in the Czech Republic or the U.K., they laugh at how many pills we bring with us. And I don’t know about you, do you take many pills?

Kevin Pho: I take some pills, yeah.

Amy Baxter: Less than five?

Kevin Pho: Less than five, yeah.

Amy Baxter: Yeah. I find that a lot of physicians are often more reluctant to take medications, even over the counter. So I started trying to figure out what exactly it is that makes us not want to travel without our Claritin, and maybe an albuterol inhaler, and maybe a couple of others, ibuprofen for sure, and Tylenol just in case that doesn’t cut it, and then they’re laughing at us for having that plus a leukotriene inhibitor.

But looking back at the reason why we are so suborned by pharma in many ways, I had a couple of different theories about how it related to the opioid crisis. One was that we were trained on statistics using pharma, trained on derm using pharma, trained on most everything, because pharma can afford the best statisticians, the best writers, the best research. And so in medical school you’re trying to learn off really quality pieces, and that’s where we learn.

My other theory was that we take multiple-choice tests to get into medical school, so we’re really used to having one right answer and believing that there is one. But when it came to opioids, I felt that the Sackler Purdue Pharma lectures made us not just think that for a while opioids weren’t addictive, but also really left us with this lingering belief that we could solve the problem of pain with a pill. And that premise was part of why I wrote this article.

Kevin Pho: So you wrote that insurance coverage of opioids is preferred over non-pharmaceutical options. Tell us a little bit of context about why that is and how prevalent that is.

Amy Baxter: Yeah, so this is really interesting. The deeper in now, the conflict of interest is well declared: I started using mechanical stimulation for pain blocking in 2006, so I make devices that block pain. And as I have tried to get these available and inexpensive and covered by Medicaid and Medicare, I’ve learned a couple of interesting things.

So the first thing, and this is in Dopesick and lots of other books about the opioid crisis, is that we don’t pay for non-pill solutions. It’s $2 a pill for a Percocet or an OxyContin, and even to get a heat pack is going to be 15 bucks at CVS or more. So hot, cold, getting a massage, being able to have access to swim, I swim a lot, or a yoga class, all of those things are much more expensive than having a pill. And this is where it comes from.

Medicaid and Medicare are funded from an 1862 statute where they are given the responsibility of taking care of seniors who have illness or injury or bodily malformation. So the illness part has really predisposed what is covered, pharmaceuticals, and the injury part has really predisposed orthopedics and orthopedic surgeons to get paid. The problem is that there’s not a balancing or a cap.

So two interesting things that have happened recently. One is, and this wasn’t recent, but it really shows where we are: My uncle W. during COVID had a burst blood vessel, and it turned out he had a tumor that had been eating from his kidney into his lungs. So my aunt, who is from Russia, goes with him to the emergency room, his lungs are full of blood, they admit him to the ICU, and he stabilizes after a couple of days. And so they send her to pick him up that day with prescriptions. So what do you think he gets? He also had some atrial fib while he was in, so they give her a prescription for Eliquis, I know, the bleed, but whatever, Eliquis, and a combination inhaler.

And so, she’s originally Russian, their insurance has run out, she’s being dumped with him to take him home that day, and she has prescriptions. She goes to the pharmacy and it’s almost $1,000. And then she goes to another pharmacy, and then she calls me, and she has no idea, she’s like, “You know, Eliquis.” So I talk to her doctor, I find some samples for her. But the bottom line is that this happened again about a week before his death, and so she spent $2,000 of money that they didn’t have in their bank account for medications that could have been $5 warfarin and a $20 albuterol.

So this is sort of elemental, underpinning the issues of not taking care of pain properly in our country, because the amount of money that Medicaid and Medicare get to spend is fixed, but $17 billion of what is spent in the Medicare budget is spent on Eliquis, one drug. And so there’s no way to allocate one pot of money for another.

And the other thing is, with this focus on bodily malformation, so part of that statute the CMS clings on to, it says they don’t pay for comfort items. Yet they have a lot of, right now, opioid-preventing indications to take care of pain, but they’re really still looking for more pill solutions. And there’s not a good mechanism, first of all, to distinguish what is comfort versus pain, and second of all, they’re strapped. And if there’s no way to move money from medications, and if physicians and patients can be advertised to and pick whatever medication they want, then, or at least ask for, ask your doctor about the one that really costs a lot. I think that those are where the threads are of the problem.

Kevin Pho: So now, for those who aren’t familiar with how Medicare decides what is covered and what is not, just give us a 30-second primer of that decision-making process.

Amy Baxter: Sure. So when medications are approved by the FDA, Medicare and Medicaid will almost always look at the FDA’s Center for Drugs recommendations and take it, and then they will cover it. And when Medicare and Medicaid cover a medication, then insurance companies usually fall in line.

With a medical device, the FDA can approve it, can say that it is indicated for treating something, but Medicare rarely covers it. So there’s something called, there’s a couple of different categories of Medicare, there’s DME, durable medical equipment, there are CPT codes, which is, you can buy this for your practice and then bill using this tray for laceration repair. So they’re different categories.

And what happens with the DME, there are four different regions in the U.S., and so when you apply with a medical device to have it be considered durable medical equipment, most of the things that are covered, splints and beds, those are to deal with the bodily malformations. If you have a novel device or novel technology, then if there’s no code under which they can put this, it’s called a HCPCS code, if there’s no way that somebody can put it on an invoice or put it on a billing, this is the device that I prescribed with this code, no code, there’s no possible way for this to be used in practice.

It used to be you could use a miscellaneous code, and that was fine because people could still use that code. But now, because it takes so much time, and overriding a computer system means about an hour of labor, no one will use the miscellaneous codes anymore. So what happens then is the DME group says we’re not going to cover you, because either it’s not durable, it’s not used at home, it’s not primarily used for a medical reason, or in the case of pain devices, they say this isn’t for pain, it’s for comfort, and we don’t cover comfort items.

So it’s very byzantine. But at least when it comes to the opioid crisis, there are an awful lot of combinations of comforting items that can be used instead of opioids and will reduce the use. There are also novel technologies that reduce pain. But so long as CMS can call it a comfort item, it will never get to patients who can’t afford it.

Kevin Pho: So from a patient standpoint, it is significantly cheaper for them to fill a Percocet prescription or an oxycodone prescription than it is to get some type of non-medication-based device to help with their pain.

Amy Baxter: That’s right, absolutely. Well summarized, my friend.

Kevin Pho: Yes. So what would be some FDA-approved devices for pain that would make sense for Medicare to cover?

Amy Baxter: Well, I always feel awkward at this point, because certainly what would be great is some body pillows after, say, shoulder surgery. One of the biggest issues after any kind of shoulder surgery is sleep, and sleep is medicine. Being able to get deep restorative sleep decreases irritability, increases pain management. So there are specific kinds of shaped pillows that will hold the body so that people can sleep better. Those aren’t covered.

There are the devices that we have been making for years, so they use a certain kind of mechanical stimulation to interrupt the pain signal and also increase blood flow. One of the things that CMS actually said this time was they considered mechanical stimulation to be distraction.

So what was interesting was, I went back in the literature, and it turns out when we started with this idea of gate control, the idea that touch nerves can override pain nerves, that was in a publication in 1965 by Melzack and Wall. But the interesting thing is that spinal gating actually started in 1960 with a paper by Wall that was called “Pain, itch and vibration.”

And so when you go into the literature, it all really got explained by some amazingly fastidious work by a guy named Mike Salter. So what Mike Salter did was, he took cats and they cut the spinal cord at L1 so there was no descending inhibition. Then they put in probes, neuron-specific, at L5, so they actually went into the dorsal horn of the spinal cord, and they looked at what made each of the nerves fire. So the nociceptive, the pain nerves, they looked at what made them fire, and then they also looked at what inhibited them.

So in the dorsal horn, and this is all medical school stuff that I forgot, but in the dorsal horn of the spinal cord it’s like this magician room of input soup, and so 95 percent of the neurons there are deciding what gets to go to the postsynaptic nerve, so what gets to go up to the brain in the dorsal column, or what goes across the spine and then goes up the spinothalamic column. I know I’m in the weeds, let me get out of it.

Bottom line is that this guy with 57 cats, what he found was that vibration and proprioception, so the Pacinian nerves that figure out where we are in space, that was what released the adenosine and stopped the pain transmission, and all of the other touch nerves don’t actually even make it into the spine.

So one thing from this is, OK, the reason spinal cord stimulators don’t work is that they are put on top of this dorsal column of the other touch signals that are going up to the brain, but it’s after the pain’s already left. So you’ve already had your neuromodulation magic in this dorsal horn chamber, and pain’s gone one way and all the other sensations go up. So hitting those postsynaptic nerves isn’t going to help much.

But the other thing is that all of these cats were anesthetized, so they could see when the pain firing flatlined and stopped. And so we know that there are specific frequencies of vibration, orientations, amplitudes, that make that pain signal stop, that have nothing to do with whether or not the cat is paying attention.

Kevin Pho: Now, is this a Medicare-specific thing? Are there private insurers that cover medical devices for pain that Medicare won’t, or do private insurers just follow the lead of Medicare?

Amy Baxter: Private insurers sometimes will change decisions on things, but in general they follow the lead of Medicare. Now, particularly for things like spinal cord stimulators, as the research is coming out that they’re no better than placebo from an opioid use standpoint in clinical trials that were published in 2023, a Cochrane review that didn’t find that there was substantial clinical benefit, because of that a number of the insurers are now declaring spinal cord stimulators to be experimental treatment. So they’re backing off. But being covered by Medicaid is in general a necessary condition, it is not always sufficient.

Kevin Pho: And this applies to non-opioid pills as well, or therapies, things like acupuncture, CBD oil. None of those alternative treatments are covered by most insurers and Medicare, is that correct?

Amy Baxter: No, well, actually acupuncture is. And what is really interesting to me is that it is different in different areas of the country. So for example, a doula or a midwife may be covered in some areas but not others. Acupuncture has really good sham-controlled clinical trials now, not every one, and that’s one where local coverage, for example, I do not know if it is covered in the Southeast, but it is widely accepted and covered in California and in the West. Some of it’s because they’ve got a better density of practitioners who are trained and licensed to do it, but it certainly is covered. Chiropractors are covered many places.

So there are other kinds of services that are covered, but those would be considered under the CPT codes, and they would not be considered under the codes that allow people to actually have efficacy and agency and decide themselves, well, I want ice packs, and I want a massage, and I want this and that, making your own plan. It’s like making an IKEA product, right? If you put it together yourself, you like it better. And with pain plans it’s the same thing, people need the agency to be able to put it together themselves. But if you can’t afford any of the kit components, it’s hard to make people feel empowered over pain.

Kevin Pho: Now, if Medicare covered some of these medical devices that you’re talking about, do you think that would make an appreciable difference in the opioid crisis that we’re facing?

Amy Baxter: So indirectly, Kevin. I mean, this is what I think the issue is. Physicians are slowly, either by their hospital rules or because of reading the newspapers, they’re not prescribing as many opioids as they used to. And the problem is that we went into medicine to help people, and many of the surgeons I’ve talked to feel very distressed at not having something to offer their patients.

So there are a couple of ways that this will help the opioid crisis. The number one is that most of the new opioid use disorder comes from pills recently prescribed and left over. So the people who misuse opioids for the first time, 80 percent of them are grabbing it from somebody’s medicine cabinet. So this means that if we can give surgeons comfort that their patients won’t have pain, then they will write for fewer opioids and there’s less likelihood of them being in the medicine cabinets. So it’s almost one to one with the excess opioids prescribed for surgeries and the new opioid use disorder cases. In terms of pills, those almost exactly balance each other every year.

So by shutting off the faucet of new unused pills, we will definitely impact the opioid crisis, and will make people less comfortable looking at a pill and thinking I’ll give it a try in high school when it actually could be laced with fentanyl. So the less familiar, the less normal it is to take an opioid for any reason, that will help the crisis. And in order to do that, we need to give prescribers a host of other options that their patients can use that can mitigate pain. So it’s a long process.

Kevin Pho: We’re talking to Amy Baxter. She’s an emergency physician, she’s also the CEO of Pain Care Labs. Today’s KevinMD article is titled “The preference for insurance coverage of opioids over non-pharmaceutical options explained.” Amy, let’s end off with some of your take-home messages that you want to leave with the KevinMD audience.

Amy Baxter: Most encouraging thing is that there are so many hospitals that are finding ways to offer options. And these ERAS, enhanced recovery after surgery, are also gradually moving away from just advocating gabapentin or over-the-counter medications to really being more comprehensive and going back to the biopsychosocial model for pain management even after surgery, which is the one that we know is very effective, works.

Kevin Pho: Amy, thanks again for coming back on the show and sharing your time and insight.

Amy Baxter: Thank you as always for having me, and I appreciate what you do.