By Terri Lewis PhD.
Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria (SAMHSA.gov). Included in the list of substances that can be routinely abused are alcohol, tobacco, opioids, cannabis, hallucinogens, stimulants and over the counter medications.
Opioids are routinely used to quell the symptoms of cancer and noncancer-related chronic and chronic intractable pain. They successfully reduce the perception of pain for some (but not all) individuals, allowing one to achieve some modicum of functionality throughout their days. Used without proper supports and education, they can also produce drowsiness, mental confusion, euphoria, nausea, endless constipation, destroy the liver, and, depending upon the amount of drug taken, depress respiration. Symptoms of opioid use disorder may be reflected in people who are not properly supported in the use of these medications and show up through behaviors associated with euphoria, attempts to magnify the drug’s impact by crushing, snorting or injecting them or combining them with other substances or over the counter medications. People who are under medicated may cut their medications in half to extend their availability or alter their dosing schedule – both lead to poor treatment effect, increase the appearance of reduced functionality, and may lead to conclusions of substance abuse.
So what do we call it in the current environment when the purposeful under-prescribing or withholding of schedule II medications results in clinically and functionally significant impairment that increases health problems, disability, and failure to meet major responsibilities at work, school, or home?
What is it called when forced reduction or replacement of medications which have allowed you or your loved one to function result in substitution with placement prescriptions or the use of OTCs with little or no therapeutic benefit?
What is it called when you’ve tried every alternative available to you and nothing is working for reasons that are beyond your control?
According to the accepted definitions, this condition amounts to what the system recognizes as ‘substance abuse’ (or torture, or a violation of human rights depending on your mood). In this case, the abuse is imposed by clinical and therapeutic prescribing practices derived from poor system capacity, incomplete provider clinical knowledge, misapplied regulation, or inadequate system capacity due to poor planning. And it’s a real problem that we all know is the elephant in the room. While the blind men are arguing about the pieces and parts of the elephant, consumers have to survive. And so do clinical providers – it is imperative that we get focused like a laser on the same things.
As state regulations are being installed that limit prescribing practices to specific MME thresholds reduced or substituted from prior successfully maintained regimens, patients find themselves forced into rapid reduction to arbitrary dose levels as the result of clinic closures, prescriber fears, and the imposition of ‘fail first’ routines. This puts patients at risk of looking for alternatives to palliation just to cope with the change – alcohol, tobacco, over the counter medications, unregulated (and in some cases unsafe or illegal) herbal compounds, and so forth. This adds to vulnerability and increased risk of harm.
Whatever one believes about substance abuse, addiction, or treatment for chronic pain, the current climate requires us to be alert to the emerging problems of care delivery because they lead to errors – of assumption, practice, and data collection. They harm consumers in ways that include:
Errors that occur due to misalignment of federal and state regulations. There are substantive conflicts between federal Medicare, state Medicaid, and private insurance regulations and emerging state laws. A change in patient eligibility criteria can have catastrophic access to care consequences. Where requirements are emerging that primary care physicians to turn their prescribing roles over to Board Certified Pain Management or Addiction specialists, the patient loses long-standing working alliances, even as specialists will be struggling to serve more complex patients with fewer resources. There is after all, only so much one can accomplish in 15- to– 30 minute office visit.
Errors that occur due to handoffs from one insurance plan policy to another. Your primary and pain management providers may be members of insurance plans that impose widely different conditions which have the possibility to lead to no treatment, reduced treatment, long waits for treatment, wrong treatment, and inconsistent demands placed upon your pocket. In some cases, insurance policies will not pay for monthly pain management visits or urine tox screens, and your existing regimen of pain management may not readily transfer due to policy constraints. The same may not be true if the frequent urine tox screen is provided by a facility treating substance abuse. Some providers are already refusing to accept patients who do not have the resources to completely comply with treatment conditions.
According to Medicare.gov, “medically necessary” is defined as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” Disparate definitions for determination of medical necessity for treatment may significantly impact how one transitions from primary care to the care provided by a Board Certified Pain Management specialist. The regulation of medicine is managed by state Boards of Medicine who find themselves increasingly determining policy against a political rather a medical standard of care. How your primary care physician prepares your medical records for this handoff is important – accuracy, communication, and collaboration are critical.
Between policies, drug formularies may not account for your particular combination of medicants – thus forcing you into alternative medications with which you have no patient experience – your receiving physician will have no initial basis to judge your response to treatment and may reset your regimen of care. This is referred to as step therapy or ‘fail first.’ Some insurers (Cigna) are now asserting that they have responsibility to reduce opioid prescribing by increasing benefits for alternative services. Until Center for Medicare Services follows in this fashion, we are unlikely to see a consistent approach to coverage.
Errors that occur due to geographic variations of regulation across states. Your residence address and medical community may cross state lines with conflicting state regulations. As of yet, Boards of Medicine have not established reciprocity agreements. Your primary care provider may have an address in your home county but your pain management provider is located across state lines – this could well require you to substitute specialty services or obtain lesser treatment for half your problem because of gaps in criteria eligibility. For instance, the depression that often accompanies complex pain syndromes may be eligible for mental health services. But in the absence of a pain management physician, your mental health or substance abuse provider will not treat you for pain or even grasp your distress. Or, your mental health physician may substitute antidepressants and antiepileptics for treatment of pain – which in turn leads to significant problems of polypharmacy without reduction of symptoms. At the extreme, your substance abuse provider may withdraw all medications entirely, theorizing that your use of schedule II narcotics is due to substance use disorder. How this is perceived is very likely to reflect the practitioners orientation and training and not necessarily your characteristics, history, and needs. Your referring physician has an obligation to determine the qualifications and capability of the person they are referring you to.
Underserved patients with chronic pain are just as likely to be negatively labeled with red flags as is the person who has an active substance abuse disorder. This is a function of systemic error, not a function of patient misconduct. It places the patient at risk of unnecessary harm and vulnerability to substandard health care practices.
In a time when reduced service leads to federal reward for reducing the cost of care, how should we cope with this transition?
- Examine your medical records for accuracy and completeness. If you can’t do it, ask someone you trust to do it. If there are errors in your records, ask your provider in writing to correct them or delete wrong information. You have a right to accurate records and to control what information is released to whom.
- Make sure you have an advocate or family member with whom you can share your medical information. Make sure that this is updated annually. Have them call to test the records management system in your provider’s office to insure that their name pops into the appropriate fields of information.
- Obtain a copy of your insurance policy. Know what it says. If your care needs are complex and require coordination across providers, contact your insurer and ask them to assign a case manager to you who can be available to help with coordination of services.
- Educate yourself about your service system options. Across the systems of care, criteria for access to services are different. While we should be able to work from a position of ‘every open door,’ we are not there yet. There are significant limitations between primary care, specialty care, substance abuse treatment services, mental health care, and other systems. The service system is not seamless. Insurers change their catalogs frequently. Providers drop in and off. By law, insurance carriers are required to keep this information current – so far this isn’t working uniformly. You have the right to insist on treatment by a provider who is qualified to meet your treatment needs. If the person you need is not on your insurance catalog, ask them if they are willing to be added to your plan and insist that they be added.
- Some insurers are operating from a position of ‘capitation’ – collecting premiums for services and service providers who are in fact not available to patients – they not taking new patients even though they are on your plan, are on your plan but are not qualified to treat you, or who may have a ‘checkered history.’ You have the right to receive safe treatment from hospitals and healthcare providers who are qualified to treat you and who do not have a negative history associated with patient harm. Check your state licensing registry for information about complaints that may have been filed or are pending against treatment providers.
New behavior is required of consumers as this system is shaking out. We have the right to expect communication between the sectors of our healthcare system. How we respond to these changes has a lot to do with both how we cope in the short term, and how the system responds and corrects itself based on real practice evidence. Here are some helpful resources to help you understand minimum requirements:
National conference of state legislatures (Review your state’s pain laws) http://www.ncsl.org/research/health/preventing-prescription-drug-abuse-pain-clinic-regulation-postcard.aspx
Federation of State Medical Boards (Here’s where you file a complaint for abandonment, poor care, or lack of provider availability) https://www.fsmb.org/state-medical-boards/contacts
National Association of State Insurance Commissions (Contact your state if your insurance provider is not meeting their contract terms) http://www.naic.org/state_web_map.htm
Center for Medicare Services Handbook (The mothership – everyone copies these requirements) http://www.ncsl.org/research/health/preventing-prescription-drug-abuse-pain-clinic-regulation-postcard.aspx
National Association of Medicaid Directors (State Medicaid programs requirements) http://medicaiddirectors.org/
How to find out whether your insurance carrier has competent health care providers in their catalog (Lookup a provider or health care facility) http://www.nolo.com/legal-encyclopedia/how-find-complaints-against-doctor-hospital.html