Let’s fix the cause, rather than the problem, of opioid addiction

Let’s fix the cause, rather than the problem, of opioid addiction
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It seems like every day there’s another headline about a death related to a drug overdose and while the government-created task forces in various states and federally are a great start, they’re not addressing the root cause of the sobering epidemic plaguing the country.

Many people don’t understand that one significant problem leading people into a life of addiction is that all too often insurers either don’t cover or limit access to Schedule III drugs that are far less addictive, but equally effective, pain treatment medications. They do however cover generic Schedule II opioids such as fentanyl and oxycodone, which have a much higher risk for abuse, dependency and addiction.

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Additionally, many insurers require a burdensome prior approval for buprenorphine, an extremely effective Schedule III drug, yet cover common Schedule II opioids with little or no prior approval needed, despite a much higher risk for addiction and diversion.

Buprenorphine is unique because not only does it work well for chronic pain, it seems to have less likelihood of developing tolerance/dose-creep, and less cognitive impairment. It also exhibits a “ceiling effect” on respiratory depression, reducing the risk of death due to overdose.

The classification and scheduling of drugs is largely regulated and enforced by the Drug Enforcement Agency (DEA). The classification for each drug is determined by the potential for abuse and addiction with Schedule III at a lower risk and Schedule II and Schedule I at the highest risk. If this is the case, why are insurers permitted to deny access to less addictive Schedule III drugs such as buprenorphine and putting patients on a slippery slope to addiction by first requiring them to try highly addictive opioids to treat chronic pain?

The answer is simple, the system is gamed for insurance companies to profit off cheaper generic Schedule II drugs leaving doctors to prescribe them first over Schedule III drugs, which are proven to be equally effective at managing and treating chronic pain.

This “fail first” philosophy may line the coffers of insurers, but it fuels the addiction crisis. What’s more, the Centers for Disease Control (CDC) guidelines suggest doctors first start by prescribing patients with the more addictive Schedule II immediate release opioids rather than the less addictive buprenorphine products. The CDC prescribing guidelines to doctors do not distinguish buprenorphine products from common Schedule II opioids, despite buprenorphine’s lower potential for addiction and abuse compared to more commonly prescribed Schedule II opioids.

I would much rather prescribe my patients who are suffering from chronic pain the chance to try a drug that is less risky. As an addiction psychiatrist and former director of an Air Force addiction treatment program, I see no better example of this catastrophic policy in action than when it comes to our nation’s veterans.  

The wars in Afghanistan and Iraq resulted in a generation of soldiers with complex pain and risk for substance use disorders. Yet most commercial plans, and even the VA formulary continue to insist on first failing at least three immediate release opioid analgesic agents such as Percocet and Vicodin, before approving buprenorphine for pain management. Yet evidence shows that buprenorphine controls pain quite well in this population with much less risk of abuse/overdose, and may even some unique benefits in treating PTSD.

As policymakers nationwide are looking to address the growing and harrowing epidemic they should consider the root cause and take a long hard look at the policy barriers that game-changing drugs such as buprenorphine face when it comes to treating chronic pain. Wouldn’t it make more sense to allow patients access to effective and less harmful drugs as a first treatment rather than beginning with the more addictive opioids on the market? If there’s a way to provide a better quality of life for those suffering with chronic pain while also combating the root cause of addiction, shouldn’t we try?

If prescribing and granting access to less addictive drugs could save thousands of people from a lifetime of addiction — it’s time for policymakers and physicians such as myself to tell insurers enough is enough.

Matthew S. Keene, MD is the executive director of the Scottsdale Center for the Advancement of Neuroscience (S.C.A.N.).