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As the opioid crisis grows, states are opening Medicaid to alternative medicine

As the opioid crisis grows, states are opening Medicaid to alternative medicine

By Casey Ross STAT (January 17, 2018)

The quickest way to erase pain is to give patients an opioid. But a rise in prescriptions has fueled a national epidemic of fatal overdoses, with a large share of the deaths occurring in low-income communities.

Under intense pressure to combat the problem, states across the country are expanding their Medicaid programs to cover alternative treatments such as acupuncture, massage, and yoga. The effort could increase non-opioid options for low-income patients suffering from pain. But it also opens states to criticism from skeptics who say taxpayers are being forced to fund unproven treatments based on political expediency instead of sound science.

Ohio’s Medicaid department took the most dramatic step this month by extending coverage of acupuncture treatments delivered by non-medical providers for patients with low-back pain and migraines, a step likely to allow much greater access and attract new practitioners to the field.

But Ohio is not alone. Eleven other states have implemented policies to encourage beneficiaries to use alternative therapies to help manage their pain and limit reliance on opioids, according to a 2016 survey by the National Academy for State Health Policy. In addition to acupuncture, covered services include massage, yoga, chiropractic manipulation, and various forms of physical and behavioral therapy, among others.

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Two states, Maine and Vermont, are currently considering whether to expand coverage of acupuncture to treat pain after conducting studies to test its effectiveness for beneficiaries.

The trend raises vexing questions: In the quest to turn the tide of the opioid epidemic, how far should states go in embracing new or unproven medical interventions? And if they shun those treatments, what else should they do?

Existing evidence offers few answers

Alternative pain therapies are just beginning to enter the mix of responses to the opioid crisis, as states move on from rewriting rules surrounding prescribing practices, said Kitty Purington, a senior program director for the National Academy for State Health Policy. “States are acutely invested in this issue and are working on a number of fronts,” she said.

But the effort to encourage Medicaid beneficiaries to use alternative treatments is politically and financially fraught. Supporters say it is a crucial part of the strategy to limit opioid prescriptions and curb abuse. But skeptics argue it has the potential to significantly increase costs for therapies whose medical benefits are unclear.

“They’re probably at risk of wasting a lot of taxpayer money,” said Dr. David Gorski, a surgical oncologist and editor of the blog Science-Based Medicine. “If you spend money on treatments that don’t work, treatments that are pseudoscience, that’s money that not going to potentially effective treatments.”

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“If you look at the overall evidence, there’s one thing that becomes clear,” he said. “The more rigorous the study, the smaller the effect, which is approaching zero.”

Acupuncture is at the forefront of the debate. Several states are covering it, or considering doing so for certain types of patients. But the evidence of its effectiveness remains unclear, even in clinical circumstances with a large body of published research.

The Cochrane Collaboration, an international network of researchers who specialize in evaluating medical evidence, has issued a variety of judgments about acupuncture’s efficacy. The group’s reviews find that acupuncture offers a small, short-term benefit for patients with chronic low-back pain, but notes that most studies are of low quality. It concludes that acupuncture can help arthritis patients, but that the benefits are too small, and too susceptible to placebo, to be considered clinically relevant. It also offers a qualified endorsement for its use on migraine patients, finding that acupuncture offers a small benefit and can reduce the frequency of attacks.

Even backers of acupuncture do not suggest it’s a cure-all, but worth a try for patients in need of relief.

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“Acupuncture is not going to solve the opioid crisis,” said Robert Davis, an acupuncturist who led Vermont’s Medicaid study. “But acupuncture is one tool that helps patients. It helps them get their feet back under them.” Vermont’s study found that, among about 150 pain patients, acupuncture improved patients’ rating of pain, fatigue, depression, and other measures — though the study didn’t include a control group, and so may have reflected a placebo effect.

Several professional organizations have also endorsed the use of acupuncture in specific circumstances. The American College of Physicians published a guideline last year calling for low-back pain to be treated with non-drug therapies such as superficial heat, massage, acupuncture, and spinal manipulation.

States take a variety of approaches

As states weigh the evidence and opposing arguments, many are moving cautiously. In Vermont, the Medicaid department is still considering how to translate the findings of its study into recommendations to state lawmakers, who will ultimately decide whether to expand coverage.

“If we add acupuncture, is it just going to be an extra million dollars that Medicaid spends without saving a million dollars somewhere else?” said Dr. Scott Strenio, medical director of Vermont’s Medicaid department. “Does it really help people more than what we have available now?”

It is unclear how much acupuncture would actually cost states. In Ohio, it could be used on more than 100,000 Medicaid patients with diagnosed pain conditions; each treatment session costs between $75 and $125, but the frequency of the sessions depends of the clinical circumstances.

Strenio said his department is examining the possibility of creating a benefit that would allow Medicaid patients to choose from a menu of treatment options after undergoing an evaluation by pain specialists. “You could design a plan that maybe incorporates a number of different modalities, including acupuncture, if that was felt to be a key component,” he said. Such a plan would allow members to try a variety of therapies, instead of “just popping an opioid.”

Oregon has created a similar approach, according to the survey by the National Academy for State Health Policy. The state covers several treatment options for patients with low-back pain, including acupuncture, chiropractic care, physical and occupational therapy, and behavioral therapy. The state also recommends treatment plans that include yoga, massage, and exercise therapy, although applicability of those services is determined by organizations that coordinate care for Oregon’s Medicaid beneficiaries.

Alabama has also considered expanding its treatment options for chronic pain. But a spokeswoman for the Medicaid department said the state decided against it after encountering multiple barriers, including limited access to local pain specialists and concerns about the additional administrative burdens the expansion would place on that small group of providers.

“For these reasons, we are encouraging use of existing services along with our current pharmacy program controls,” the spokeswoman, Robin Rawls, wrote in an emailed statement.

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In Ohio, which is combatting an especially severe opioid abuse problem, public officials have taken a more aggressive tack. An opioid task force convened by Gov. John Kasich released a variety of recommendations in January 2016 for managing acute pain outside of hospital emergency departments. The list included non-opioid treatments such as massage, acupuncture, chiropractic adjustment, hypnotherapy, and biofeedback, a treatment that involves attaching sensors to patients to help monitor and control the body’s functions.

In 2017, the state’s Medicaid department opted to expand coverage for acupuncture, determining that the evidence of benefit was strongest for patients with low-back pain and migraines. Initially, the state authorized the treatment only when deemed medically necessary and delivered by a physician.

But physician practitioners of acupuncture are not always easy to find. So this month, the agency expanded coverage to include care provided by licensed acupuncturists and chiropractors, and included coverage for acupuncture with electrical stimulation.

A spokeswoman for Ohio’s Medicaid department said officials were careful to limit coverage to conditions for which there is strongest evidence of benefit. “We reviewed the literature in great detail with national subject experts across multiple states,” said the spokeswoman, Brittany Warner. “The strength of the data is strongest for our covered conditions as acupuncture effectiveness was tested compared to a ‘sham’ procedure (needles placed indiscriminately) as opposed to nothing.”