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Join us as we sit down with Amy Baxter, a clinical associate professor of emergency medicine, to explore the future of pain management. We’ll dive into the challenges and advancements in non-opioid alternatives, focusing on the impact of the NOPAIN Act set to transform reimbursement policies in January 2025. Amy will share insights on the importance of multimodal pain management, ERAS studies’ biases, and mechanical stimulation discoveries. We’ll also discuss how opioid settlement funds are being used to educate medical staff on innovative pain management strategies.

Amy Baxter is a clinical associate professor of emergency medicine at Augusta University, federally funded for neuromodulation research to reduce needle pain, multimodal low back pain, and opioid reduction.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, 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 medicine physician. Today’s KevinMD article, we’ll talk about that intersection between non-opioid alternatives and the future of reimbursement. Amy, welcome back to the show.

Amy Baxter: Good, as always, to be here. Thanks for having me.

Kevin Pho: So Amy’s been on multiple times. Go to KevinMD.com/podcast to search for her name, hear her story and prior episodes. But today let’s jump right into your most recent KevinMD article, where we talk about that intersection between non-opioid alternatives and the future of reimbursement. For those who didn’t get a chance to read that article, what’s it about?

Amy Baxter: Well, the series that I’ve been building is this concept that our opioid crisis stems from having unused opioids on people’s counters, from the about 6 percent of people who will become opioid use disorder patients after even a single surgery due to their genetics, and then the reasons why we don’t offer alternatives for people after surgery.

This article brings us to the place where we now have an upcoming opportunity for reimbursement of non-opioid choices, but the other barrier is physicians’ awareness of what is evidence-based and actually works for management.

Kevin Pho: But when you say non-opioid alternatives, what exactly are you talking about?

Amy Baxter: So a lot of people will conflate ERAS, or enhanced recovery after surgery, with gabapentin or scheduling Tylenol and ibuprofen and alternating them. Really what enhanced recovery after surgery means is using multimodal approaches to reduce pain.

In other countries, no one gets prescribed opioids to go home after surgeries. Now, some of the reason, like in Japan, is because after a total knee they will keep people for three days instead of sending them home same day. Some situations, like in Sweden, it’s because the people are actually a bit more stoic and they are just not prescribed opioids for home. And some places are able to keep patients in house longer for other reasons, and so they don’t prescribe opioids for home because they’re kept in the hospital longer.

What I mean by non-opioid alternatives is getting really to the nature of pain itself. I did a TED Talk which was recently featured on an NPR podcast, the TED Radio Hour, and what I talk about in that is the nature of pain. Physicians are only taught about 12 hours of pain education throughout medical school, and most of it is on pharmaceuticals. But because of functional MRI, what we know about pain now is that pain is really your brain’s thinking fast opinion of how safe you are. What opioids do is they make your brain not care, by hitting the reward centers. So you know you’re in pain, but you feel safe, because there’s so much neurotransmitter reward.

What I talk about in the TED Talk, and what non-opioid alternatives really means to me, is that yes, there’s a small number of over-the-counter medications that can help, there’s a bigger amount of supplements that can enhance your pain management after surgery, but there is a huge number of physical interventions that can reduce pain, heat, cold, vibration, pillows to prop you up. And there’s an even bigger amount of alternative activities you can do that can give those neurotransmitter rewards without opioids.

Kevin Pho: So let’s expand on the last one. What are some examples of those physical modalities that you’re talking about?

Amy Baxter: Yeah, well, I think that it’s important not to just talk about physical modalities, because the concept of ERAS and non-opioid pain management is, all options are on the table.

After the TED Talk got a lot of attention, we made a booklet that’s a free download that’s called What Works for Pain. And this booklet goes through a whole lot of different things people can try and plan before a surgery, so that when they’re feeling pain they know when the pain’s going to be the highest, so they can tell the brain it’s OK, you don’t need to be as worried. Decreasing fear is a huge part of this.

So there’s a group that is being funded now by the opioid settlements in a number of states. So Goldfinch Health will provide an adorable little lunchbox to patients preop, and in it there’s a pain plan, there’s these kind of What Works for Pain ideas, so people can plan for pain and not be as afraid of it.

There are things to make recovery better, which has correlates to decreased pain postop. So one of them is a clear sugar drink that you can have four to six hours before surgery that doesn’t conflict with NPO but does provide some substrate, so that the body recovers better after surgery.

There’s VibraCool, which is one of our devices. What VibraCool is, is a specific frequency of mechanical stimulation for neuromodulation, which is about 200 hertz, but it’s also heat and cold. And having the option to choose one or the other as a postop, and even preop, pain relief decreases fear, increases comfort, and gives someone something to do, so that they’re not just trying to smother their pain awareness with opioids.

Kevin Pho: So you mentioned earlier on there’s an opportunity that is coming up that may perhaps change the course for this. Is this in the form of legislation?

Amy Baxter: Yeah, so there’s two different kinds of legislation. One has already passed. This was actually spearheaded by the senator from West Virginia, and it was signed into law in the 2022 Congress at the end of the year. It’s called the NOPAIN Act. And what this does is, this calls for Medicaid and Medicare to cover anything that has been proven, whether it’s device or drug, proven in a randomized control trial that’s peer reviewed and published, to decrease opioid use after surgery.

So January 2025, that bill, which is already law, will be incorporated into Medicare and Medicaid’s reimbursement schema. So, couple things with that. I was recently on the Hill with Voices for Non-Opioid Choices talking about this bill.

One, there’s an appropriations bill that’s in Congress now to educate physicians, because if we don’t feel comfortable with it, we’re going to still write for opioids, because we don’t want someone to have pain. The education part is letting people know that every study so far that has looked at outcomes not using home opioids has found satisfaction is the same, recovery is as good, and in fact the chance of returning to the ICU, and the chance of returning to the hospital, and the total cost of care is less when you don’t give opioids for home. So that kind of education, people won’t find out about unless we have some money that can support educating.

The other part of the legislation is making sure that people are aware of it, because to this point Medicaid and Medicare have not understood that pain is a fear of tissue damage and can be real or imagined. So that means that a lot of things that do reduce pain, Medicaid and Medicare have considered to be comfort options. So this is where we need to make sure that they don’t out of hand reject things like cold therapy, like vibration, like other modalities that have been proven to reduce opioids, but that Medicaid and Medicare have not been willing to pay for because they say they’re for comfort, not pain.

So there will be, in June, July, a public CMS comment period, that hopefully I can addend to my article, which will give people a chance to comment on how CMS is planning to interpret the NOPAIN Act in their reimbursement starting January 2025.

Kevin Pho: So the NOPAIN Act, which is already law and will take effect in 2025, will cover non-opioid modalities that have been shown in evidence to be efficacious. What are some examples that would fall under that umbrella?

Amy Baxter: Sure. Well, I think one of the biggest ones is cryotherapy. There are a number of studies now showing that things like Game Ready, which is currently not reimbursed, but having cryotherapy after surgery decreases pain, it decreases nerve conduction, it decreases inflammation, and it actually has been shown not to make a bit of difference on healing or recovery in terms of reducing it. People have always said, oh, cold, you don’t want to put that on because they won’t heal as well. Nah, that’s not true. So that has a lot of studies that have been proven, and many of them do have opioids as outcomes.

We are currently in the last part of our pivotal trial for DuoTherm, which has three different frequencies of vibration for low back pain. Now, opioid use is our primary outcome, but it is not intended at this time to be postsurgical, so it wouldn’t fall under that. Even if we were able to reduce opioids with low back pain, it won’t necessarily be covered because it’s not a surgery.

However, VibraCool, the VibraCool Extended, was looked at in a case series for ACL reconstruction, and it was found to reduce opioids 35 percent, and 13 of the 14 patients who used it were off of opioids by day four. So that’s another part of looking at opioid hygiene. The people who tend to get opioid use disorder are on for more than three days, so that four day off opioids thing is a really important part. So that study is being replicated at Columbia, and that would make VibraCool able to be reimbursed.

So, other things like the postop injections of a long-lasting bupivacaine, giving someone a really good nerve block that gets them past this, there’s some medications that seem to be more effective, and those should be covered because they reduce opioids after surgery.

I mentioned Goldfinch Health. Well, the use of their preop pain planning has actually already been found to reduce opioid use by 70 percent. It’s crazy. But again, it gets to this concept that having the brain feel less afraid decreases pain perception, and knowing that opioids are just smothering your perception of pain but they’re not actually doing anything other than increasing rewards, that’s a big deal.

So Goldfinch Health has been able to show, in the states that are using this with the opioid restitution money, a 90 percent reduction in opioid refills. And in the states that started using Goldfinch Health this summer, they found a 70 percent reduction in all prescribing. So hopefully that will enable these pre-surgery pain kits to continue to be prescribed after the opioid money runs out.

Kevin Pho: You said earlier that in order to move the needle and decrease the use of opioids, it’s not going to only involve reimbursement but also education, and the fact that you need more clinicians to prescribe non-opioid alternatives. Whenever you suggest non-opioid alternatives, or different modalities other than opioids, do you encounter any pushback from people who’ve been prescribing opioids all their life after surgery?

Amy Baxter: Oh sure. First of all, we’re up on what we’re up on. And so in medical school we’re up on pharmacology, because we learn statistics on pharmaceutical studies, we learn our dermatology on pharmaceutical side effects, we learn pain management purely as a construct of pharmaceuticals. So we’re all up on that, it’s our superpower, writing prescriptions. And it’s hard to understand or believe that maybe we haven’t been optimizing pain care for patients, when that’s our primary goal. I’m getting a lot less pushback now than I was five years ago when I started talking about giving people options instead of opioids.

The other thing is that most of the comprehensive pain plan that works requires patients to pay something. For example, magnesium. It’s a fantastic adjunct, it’s an NMDA blocker, so it decreases the amount of opioids used in surgery by a third, it is a smooth muscle relaxant, and 66 percent of patients go into surgery magnesium deficient. But since all we can test is the extracellular magnesium, we’re not aware that magnesium sufficiency has drastically reduced in all Americans, because most of the leafy green vegetables we’re getting is in soil that’s been depleted of magnesium.

That kind of education, that’s the stuff that we’re never going to get in med school, they’re not going to tell us about nutrition. But all we need to know as doctors is, most of your patients are going to have a low normal magnesium on the cellular number, but they’re actually magnesium deficient, and surgical outcomes are better when you supplement with magnesium for three days before, and pain is reduced. Because pain is, in many places the descending inhibitory control of pain is done in the periaqueductal gray by oxytocin, and that requires magnesium to work, it’s an obligate part of those reactions.

So anyway, there’s a lot of really complicated physiology we don’t know. And so if we did know that, if we can recommend people make a plan for four activities that are going to make them happy or make them feel connected, or if they get a massage or something that’s going to increase oxytocin, learning those kinds of things, or at least knowing, this is an evidence-based book I’m going to send them to, What Works for Pain, it’s a free download on PainCareLabs.com, then just that whole construct that doesn’t have to be paid for or prescribed, but it is a way that patients can take control of their pain. I think that’s really the education part of this that will be great if it can be a rising tide that we all support.

Kevin Pho: We’re talking to Amy Baxter. She’s an emergency medicine physician, and we’re talking about that intersection between non-opioid alternatives and the future of reimbursement. Amy, as always, we’ll end with your take-home messages to the KevinMD audience.

Amy Baxter: My take-home messages are that if you are a surgeon, you need to think outside the pill and become familiar with the literature, or at least the options for your patients that don’t involve pharmaceuticals that are prescription, and that really involve education.

I also think it’s important for surgeons to know, and for patients going into surgery to know, that the research is clear. Not sending people home with opioids works just as well from a satisfaction standpoint and from a pain management standpoint, but it is superior for cost, and it’s very much superior for not ending up with 6 percent of your patients with opioid use disorder.

Kevin Pho: Amy, once again, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Amy Baxter: Thanks for providing a platform and forum that allows for a rising tide to change people’s practice.