Thinking outside the bottle

When the 72^nd Colorado General Assembly launches its legislative session Jan. 8, it will have the opportunity to pass an innovative approach to stemming the opioid crisis: making alternative pain-management treatment as affordable as potentially addictive prescriptions.

On Tuesday, the legislature’s bipartisan Opioid and Substance Use Disorders Interim Study Committee advanced to the house a bill that would force insurers to cover opioid alternatives such as acupuncture, physical and occupational therapy and less-addictive drugs.

“In Colorado, we’re really on the cutting edge here,” said Rep. Chris Kennedy (D-Lakewood), the bill’s sponsor. “There are a lot of leads that people have been following on both the state and federal level, but this is taking it one step further. Rather than making it harder to get opioids, we want to make it easier to get alternative treatments for pain management.”

The committee, on which Kennedy serves as co-chair, is also planning to advance four other bills related to prevention, harm reduction, criminal-justice reform and recovery. This is the committee’s third round of attempting a comprehensive approach to address opioid addiction across the state, Kennedy said.

“This package of bills is unlike others we’ve seen before, both locally and nationally,” he said.

The need for such approaches to solving the opioid crises is acute: The number of overdose deaths involving opioids in the state has steadily climbed from fewer than 200 in 2002 to 578 in 2017, according to the National Institute on Drug Abuse.

But the impact of opioid addiction stretches well beyond the individual, said Patrick Griswold, a nurse, licensed addiction counselor and assistant professor in Metropolitan State University of Denver’s Department of Human Services and Counseling.

“It’s leaving children without parents, siblings without siblings,” he said. “There’s a whole broader impact on families and communities across the state.”

Leveling the playing field

When it comes to addressing the opioid crisis in Colorado and beyond, Kennedy sees a fundamental flaw in the current health-care system: Opioids are cheap.

“We’re trying to level the playing field when it comes to seeking other options (in Colorado),” he said. “This is such a big problem we’re trying to tackle, but we have a real chance to take it on right now by extending coverage for alternatives to opioids.”

If passed, the bill would:

• Cover on the same tier as traditional opioids alternative treatments for pain management, including acupuncture, physical and occupational therapy and atypical opiates less likely to cause addiction (such as Tramadol and Buprenorphine, used in treating addiction);
• Eliminate requirements for prior authorization or step therapy to access these treatments, the basis for many denied claims;
• Extend the current 7-day prescription limit for opioids indefinitely (unless certain exceptions are met); and
• Extend provisions for prescribing physicians to consult with a drug-monitoring database prior to refills of opiate medications or prescribing a benzodiazepine.

Last year, the Colorado Legislature passed a law allowing doctors to recommend medical marijuana for any condition for which they would prescribe an opioid. However, medical marijuana is not included in this legislation requiring insurance to cover alternative pain-management treatments.

It wouldn’t just put fewer opioid prescriptions in the hands of Coloradans, Kennedy said. This legislation also has the potential to increase access in rural communities to alternative treatments while also filling the shortfall in addiction counselors serving those far-flung locales.

“There’s limited access to treatment like physical therapy in rural parts of the state,” Kennedy said. “We’re hoping to change that by opening pathways for more utilization and access to providers.”

Access to alternative therapies often comes down to economics, explained Kelsey Asplin, N.D., a naturopathic doctor and lecturer in MSU Denver’s Integrative Health Care Program. Because many alternative therapies aren’t covered by insurance policies, they tend to cluster in urban areas with higher concentrations of wealth, where those who access their services are more able to afford them.

“A lot of health-care providers would love to serve rural populations, but right now it’s a hard case to make,” Asplin said. “If we see a bill that puts funding behind access, I absolutely believe you’d see more providers going out to these underserved parts of the state.

“In many cases, it’s not a question of if the provider takes the insurance; it’s if the insurance recognizes the provider.”

In Eagle, where Griswold lives, the closest alternative treatment options for pain management are 128 miles west in Grand Junction or 127 miles east in Denver. He’s hopeful that the legislation, if passed, would bring more trained professionals to rural areas.

“We just don’t have these types of services here,” he said. “And when you don’t have them, the only alternative is a pill.”

Understanding pain

Improving access to opioid alternatives may also improve health outcomes, according to MSU Denver’s health and addiction experts.

For instance, research suggests that opioids can increase rather than decrease pain, Asplin said.

“(Opioids) can induce hyperalgesia, which rewires the nervous system,” she said. “The result is that when someone brushes their hand, for instance, it’s excruciatingly painful.”

What’s worse is what that increased pain causes: “It easily can trigger an additional usage cycle,” Asplin said.

Among the alternative treatments that would be covered should the bill pass is acupuncture. Though it’s an ancient, traditional approach to pain management, its benefits are only now being understood by science, Asplin said.

“For a long time, we didn’t know exactly how acupuncture worked, but now we have research to show us what’s going on,” she said.

The action of breaking the skin barrier with acupuncture needles triggers surrounding cells to release endogenous opiates – natural painkillers, Asplin explained. Additional physiological responses include triggering the immune system to send blood flow and white blood cells to the area, along with increasing the circulation of the lymphatic system to remove toxins and reduce inflammation.

“Our body produces these things that are triggered by acupuncture,” she said. “In and of itself, that helps healing and decreases pain.”

Physical therapy, meanwhile, can help alleviate pain by following a foundational tenet of physical-medicine modalities called Hilton’s law: By manipulating the skin of an affected area, medical practitioners can trigger an irritated nerve to “kick back” into its connected root to address the underlying pain.

Because alternative therapies take multiple sessions, there may be a short-term rise in insurance premiums, Griswold said. Those costs would be offset by the eventual financial and social benefits of having these treatment avenues in place.

“When you consider the human toll that addiction and overdoses take on individuals and families,” he said, “those are huge savings in the long run.