As the opioid epidemic intensifies, affecting people in almost every demographic of American life, healthcare companies are feeling a similar urgency to address the crisis.
According to the national Centers for Disease Control and Prevention, 600,000 people died of drug overdoses from 2000 to 2016, with opioids accounting for 66 percent of those deaths. The gathering crisis over the past several years has compelled healthcare companies to find ways to combat the epidemic.
Connecticut is home to two of the largest healthcare companies in the country: Hartford-based Aetna is the third largest in the nation, providing services to 22.2 million members; Cigna, headquartered in Broomfield, follows as the fourth largest, with 15.2 million customers. Combined, Cigna and Aetna total more than $100 billion in revenue annually.
Within the past two years, both companies established goals describing how they plan to lower opioid use among customers and offer treatment to those suffering from an opioid-use disorder. Cigna made a commitment to reduce customers’ opioid use by 25 percent by 2019 and achieved nearly half of its goal in the first year by reducing prescribing by 12 percent. Aetna hopes to see inappropriate opioid prescribing drop 50 percent among members by 2022, in a strategy that depends on educating doctors, patients and the public about the potential harm associated with opioids.
An overprescribed culture
Doctors receive a level of respect in Western culture because their expertise helps patients and saves lives. But they are fallible, like anyone else, and as new methods and information are discovered, they must stay updated on the safest and most effective approaches to prescribing medicine. Practices doctors learned in medical school might no longer be the standard or safest modes for treating pain.
Dr. Craig Allen is the medical director of Rushford, a branch of the behavior-health network within the Hartford HealthCare system that specializes in addiction and co-occurring treatment.
“There’s this idea in the community that healthcare providers are aware of all these things, like the appropriate treatment for an opioid use disorder [OUD] and how people develop one,” Allen said. “The truth is, medical schools and graduate medical education are lacking that information, both in pain and the treatment of addictions. This is information your average practitioner may not have.”
To prevent opioid misuse before it occurs, Aetna reached out to “super prescribers,” or physicians in the top 1 percent of prescribing opioids, with a personalized letter informing them they are an outlier and included updated guidelines for treating chronic pain, according to Dr. Dan Knecht, the head of clinical strategy at Aetna.
“We need to respect the therapeutic relationship between a physician and his or her patients,” Knecht said. “But at the same time, we want to facilitate the practice of evidence-based care, so we reach out to physicians who may benefit from additional education around appropriate management of chronic pain and the use of opioids.”
Americans account for less than 5 percent of the world’s population but take 80 percent of the worlds opioid medications, according to Aetna statistics. Some experts blame a culture in the United States that does not tolerate discomfort of any kind and attribute that to the rise in substance-abuse problems.
“There’s an expectation when people go to their doctor that they’re going to get OxyContin or Vicodin, and when they don’t, they may feel gypped,” Rushford’s Allen said. “There’s an unrealistic expectation doctors share with the general population that we should all be pain-free as human beings, and that is a really unhealthy myth.”
As a result, healthcare companies are pushing for methods to deal with pain that do not include opioids.
“There are alternatives, such as chiropractic care, acupuncture, physical therapy, cognitive behavioral therapy, that are proven to help patients who have chronic pain,” said Dr. Doug Nemecek, the behavioral-health medical director at Cigna. “We make sure those treatments are accessible and that our customers understand they should talk to their physicians about alternatives.”
For someone who already suffers from an OUD, one of the most recommended courses of treatment is called medication-assisted treatment. This approach uses medication to relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body. Paired with behavioral therapy, controlled medications have proven effective in treating OUDs.
“One of the evidence-based treatments we’ve focused on at Cigna, making sure it’s available for our customers, is medication-assisted treatment with medications such as buprenorphine, Vivitrol and methadone,” Nemecek said. “These medications are an important part of treatment for somebody with an opioid-use disorder, regardless of what type of opioid they’re using.”
Aetna also supports MAT for people with OUD and made it easier for members to have access to those medications. They are the only national payer to waive the copay on Narcan, a lifesaving opioid-overdose reversal medication, for fully insured members.
“I think some pockets of some populations look at medication-assisted therapy as trading one addiction for another,” Aetna’s Knecht said. “We certainly don’t think that’s the case and feel that medication-assisted therapy is a vital cornerstone of treatment.”
Although MAT has proven to be an effective strategy, it can be difficult for patients to access the treatment and stay long enough for it to lead to recovery.
The Hartford HealthCare network developed the Medication Assisted Treatment Close to Home program, or MATCH, in nine communities throughout Connecticut where people can access evidence-based, first-line treatment for an OUD or any substance-use disorder. The MATCH program provides Buprenorphine and Vivitrol, along with therapy, at the same location and with the same team, for long-term treatment.
“When someone engages in medication-assisted treatment, they benefit most the longer they’re in it — and the studies show that means over a year and maybe 18 to 20 months, if not longer for people to be engaged in treatment,” Allen said. “So getting to know your treatment team and having the program close to where you live or work can be very effective.”
Changing the conversation
The solutions for fixing the nation’s opioid crisis still face many challenges, the largest being educating people about the epidemic and telling them how to access treatment. Talking about opioid use can be a difficult conversation for people to have with family, friends or co-workers. Stigma surrounds addiction, leading to isolation or lack of support for those seeking treatment.
“We need to get people comfortable talking about substance use disorders and opioid use disorders the same way we talk about diabetes and heart disease and other chronic illnesses,” Cigna’s Nemecek said. “Addiction is a chronic illness, and if we can change the conversations and eliminate the stigma, it will help families and individuals get treatment sooner and more effectively before there are more overdoses and unnecessary deaths.”