Senate Bill 544: Establish Non-Opioid Treatment Alternatives.

Written by Seth Hurley, Ph.D.

December 2^nd, 2019

Abstract

Senate Bill 544 aims to provide improved access to non-opioid treatment alternatives for pain. Opioids are very effective pain relievers; however, they also have additional negative side-effects. Over-prescription and reliance on opioids for pain management has led to a nation-wide opioid epidemic that has severely impacted North Carolina [1]. The North Carolina Senate proposed a bill to provide non-opioid treatment alternatives to reduce the likelihood of opioid addictions precipitated by opioid prescriptions. This bill aims to establish non-opioid treatment options for pain, mandate insurance coverage for non-opioid alternatives, and limit opioid prescriptions.

History

The over-prescription of opioids has contributed to an ongoing opioid epidemic and drug overdose is a driving factor mediating decreased life expectancy in the United States [2, 3]. Most heroin users in the United States began their opioid use from prescription opioids [4]. Opioids are often prescribed to treat pain, however there are effective non-opioid alternatives for pain treatment. That is, non-opioid treatments including acupuncture, chiropractic care, massage therapy, occupational therapy, osteopathic manipulative treatment, and physical therapy have been found to treat pain to varying degrees [5, 6, 7, 8, 9, 10]. Further, one analysis suggests that physical therapy was more effective at treating lower-back pain than opioids [11]. Despite evidence for the effectiveness of physical therapy, between 1997-2010, only 10% of patients with lower back pain were prescribed physical therapy [12].

Opioid prescriptions tripled between the late 1990s-2011 nationally but have since declined [13]. However, opioid prescriptions in North Carolina are higher than the national average [14]. With the recent wealth of research on the detrimental side effects of opioids, there has been renewed interest in reducing opioid prescriptions and promoting alternative treatments for pain [15, 16]. Complicating this transition from over-reliance on opioids is the need for non-opioid treatment alternatives to be covered by insurance and available at a reasonable cost. A nation-wide study found that most insurance policies cover some non-opioid treatments including occupational therapy, chiropractic care, and physical therapy while others, like acupuncture and massage therapy, are rarely covered by insurance [17].

The Bill

Senate Bill 544 has three components that serve the goal of reducing opioid prescriptions: 1) promoting non-opioid pain treatments, 2) limiting opioid prescriptions, and 3) requiring that insurance companies cover non-opioid treatments at a reasonable cost. The primary component of the bill mandates that health care providers offer patients a referral or a prescription for non-opioid treatments as a first line of treatment for pain when deemed appropriate based upon the health care provider’s judgement. Non-opioid treatments supported by the bill are acupuncture, chiropractic care, massage therapy, occupational therapy, osteopathic manipulative treatment, and physical therapy. If a health care provider finds it necessary to prescribe opioids to a patient, prescriptions must be limited to 5-7 days and immediately followed by a reevaluation. During reevaluation the health care provider will determine whether non-opioid treatments should be prescribed instead of continuing opioid medications. This directive does not apply to opioids delivered in health care settings (e.g., a hospital). Complying with this bill allows immunity from civil action lawsuits and disciplinary action related to opioid prescription practices. Furthermore, health care providers would receive annual training in non-opioid treatments for pain. To encourage affordable, non-opioid treatment prescription the bill removes limits on visits for non-opioid treatments, ensures that non-opioid treatment alternatives have an equivalent cost to primary care services, and reimburses at least 75% of the non-opioid treatments listed previously.

The bill also mandates that a Voluntary Non-Opioid Directive form will be made available on the Department of Health and Human Services website that allows individuals to choose not to receive opioid prescriptions. The form must be signed in the presence of a health care provider or other qualified representative who evaluates whether the patient is prone to developing an opioid addiction. The patient has the right to revoke the form for any reason. Health care providers may override the form if their medical judgement deems opioid medications necessary. This form would likely serve to deter opioid prescriptions for individuals that want to avoid opioid exposure, however in cases where opioids may be the best treatment for pain (e.g., severe pain associated with cancer [18]), the form can be overridden.

Who Supports Senate Bill 544?

The primarily sponsor of Senate Bill 544 is Ralph Hise (Republican, 47^th District), and the bill has both Republican and Democratic support by Danny Earl Britt, Jr (Republican, 13^th District), Paul Lowe, Jr. (Democrat, 32^nd District), and Erica D. Smith (Democrat, 3^rd District). Dr. Winn Sams, a chiropractor practicing in Columbus, North Carolina, helped draft and supports the legislation based upon her experience with patients seeking alternative pain treatments to opioids [19]. Dr. Sams has contributed to similar legislation that has passed in West Virginia and Delaware. Furthermore, research provides support for the bill as non-opioid treatments, such as physical therapy, are equally as effective at treating some types of pain as opioids and long-term outcomes of physical therapy may be better than chronic opioid prescription [10, 11]. For example, one study found that early treatment with physical therapy lowered the dosage of opioids needed for pain treatment and prevented the need for opioid prescriptions in some individuals [20].

Who Opposes NC Senate Bill 544?

Currently we are unaware of publicly stated opposition to the bill from North Carolina State Representatives. However, the bill has stalled in the Senate hearing committee. Of note, many opioid treatment alternatives are more expensive than opioid prescriptions and require patients to devote time performing them, leading to patient attrition [21]. For example, patients can ingest an opioid medication to receive quick pain relief but engaging in physical therapy every day can be a significant time investment and amelioration of pain may require weeks to months of therapy before treatments are effective. Furthermore, insurance agencies have voiced concern that treatments such as massage therapy may be abused by patients [17]. Finally, there is concern that the therapeutic effectiveness of some proposed treatments is equivocal. For example, occupational therapy has been found to be less effective than physical therapy [9] and pain relief from osteopathic manipulative treatment may be the result of a placebo effect [8].

Works Cited

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11. Gladkowski, C.A. et al., Opioids Versus Physical Therapy for Management of Chronic Back Pain. The Journal for Nurse Practicitioners. 2014; 10(8): 552-559.
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14. North Carolina Opioid Summary. Accessed: 10/14/2019. Available from: https://www.drugabuse.gov/node/pdf/21978/north-carolina-opioid-summary
15. NIH funds $945 million in research to tackle the national opioid crisis through NIH HEAL initiative. Accessed: 11/18/2019. Available from: https://www.nih.gov/news-events/news-releases/nih-funds-945-million-research-tackle-national-opioid-crisis-through-nih-heal-initiative
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17. Heyward, J., Jones, C.M., Compton, W.M. Coverage of Nonpharmacological Treatments for Low Back Pain Among US Public and Private Insurers. JAMA Network Open.2018;1(6):e183044
18. Caraceni, A. et al., Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. The Lancet Oncology. 2012; 13(2): e58-e68. https://doi.org/10.1016/S1470-2045(12)70040-2
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20. Sun E, Moshfegh J, Rishel CA, Cook CE, Goode AP, George SZ. Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain. JAMA Network Open. 2018;1(8):e185909. Published 2018 Dec 7. doi:10.1001/jamanetworkopen.2018.5909
21. Bishop, M. Physical therapy could lower need for opioids, but lack of money and time are hurdles. Accessed: 11/18/2019. Available from: https://medicalxpress.com/news/2018-06-physical-therapy-opioids-lack-money.html