Doctors’ Use of Opioid Alternatives Thwarted by High Costs

Ken Manning’s head is held up by two metal rods, four plates, and 17 screws in his neck.

Since falling off a frame at a carpentry job in the early 2000s, he has had four surgeries, leaving his tanned neck covered in a spider web of pale scars and a sewn-together seam that runs from his shoulders to the base of his skull.

The pain is still so bad that he sometimes “sees stars” or passes out. To cope with it, he has been prescribed opioid pain medication for more than a decade.

The drugs are some of the most addictive in the world and Manning, 54, of Tewksbury, is open about the fact that he abused cocaine in his younger days and is a recovering alcoholic who once blew a .43 on a Breathalyzer test, a near lethal level.

But for someone with his level of pain, there are few other options.

“I’m an addictive person,” Manning said. “I lived hard, but now I don’t.”

“I’ve been taking Vicodin, Percocet, Roxicet, you name it, for all these years. I told my doctor, and he couldn’t believe I said it, that I wanted off them. But I need an alternative.”

For decades, opioids have been the gold standard of pain treatment for everything from broken bones in emergency rooms and post-surgery relief to back pain and the chronic suffering of people with conditions like fibromyalgia and cancer.

In 1992, pharmacies filled more than 112 million prescriptions for opioid pain medications. Those prescriptions peaked at 282 million in 2012 before dropping to 249 million in 2015, when the country spent $9.6 billion on opioids, according to data from IMS Health.

About 2 million Americans were addicted to prescription opioids in 2014, the National Institute on Drug Abuse estimates, and many heroin users start with pills.

But there are also around 23 million Americans who report experiencing severe, daily pain. Many of them rely on opioids to function or as supplements to other treatments.

Doctors are left in a predicament: How do you shepherd someone like Ken Manning through a devastatingly painful injury, days of local pain after surgery, and then years of chronic pain without him becoming addicted to opioids and all while seeing him in the 15-minute intervals that most doctors are allowed with patients?

Some doctors are looking for alternatives to replace opioids, but there seem to be few viable options for acute pain, and chronic pain patients must often overcome significant financial barriers to access other treatments.

“There haven’t been any new developments in pain medication – like a novel class (of drugs) – since I’ve been in practice,” said Dr. Nathan MacDonald, chief of emergency medicine at Lowell General Hospital. “You would think there would be money in it for the pharmaceutical companies, but I haven’t heard of anything on the horizon for acute pain.”

Acute pain – the severe but temporary kind you might feel if you broke a bone – can often be treated by over-the-counter drugs like Tylenol or Advil. But such drugs come with limits: take too large a dose over a period of time and you can end up with long-term problems like liver or kidney damage.

“Non-opioid medications like anti-inflammatories will work to a degree with any kind of pain … but sort of the thing that makes opiates attractive is that they are infinitely titratable, meaning you can keep giving patients opiates until the pain is gone, within certain safety parameters,” MacDonald said.

At the surgical level, another Lowell General doctor has had more success finding innovative treatments.

Dr. Scott Sigman, the hospital’s chief of orthopedics, was an early adopter of Exparel, a non-narcotic anesthetic that can be injected during surgery and keep the affected area pain-free for two to three days. He also uses Ofirmev, an intravenous form of acetaminophen.

“My patients who have had a knee replacement … are literally up and walking in the hospital the day of their surgery with minimal pain,” Sigman said, adding “The problem with any of these alternatives that we’re seeing: There’s a cost associated with them.”

Exparel costs around $300 a dose while Ofirmev runs about $35 per dose, and most patients require four or more doses. Meanwhile, the average Vicodin prescription in the U.S. cost $5 in 2015, according to IMS Health data.

Since adopting Exparel, Lowell General Hospital has saved an average of $1,638 per knee-replacement patient, due in large part to shorter lengths of stay, a study of the hospital’s data found.

But for patients, especially those with chronic pain, innovative treatments are often either not covered by insurance companies or remain far more expensive than opioids.

“We have certain things like acupuncture or massage therapy, but they’re not always covered by things like MassHealth, said Dr. Hugh Silk, a family physician at UMass Memorial Medical Center in Worcester. “If I had more tools in the toolbox, I could avoid opioids even more. If we’re really going to fight an opioid epidemic, we can’t keep Percocet inexpensive and Lidoderm (a local anesthetic) patches expensive.”

Ken Manning has tried alternatives to opioids, from steroid injections that left lasted for months but left him anxious and nauseous, to a therapy called transcutaneous electrical nerve stimulation, or TENS.

His TENS machine required him to attach electrodes to his body and it worked, until he started sweating and the pads fell off. Now, he is working with a doctor at Boston Medical Center in the hopes of receiving TENS implants.

“I’ve been offered other pills that are more potent, but they’re missing the point,” Manning said. He was so eager to try anything else that he agreed to try the TENS implants before his doctor could finish explaining what it was.

“This is the newest and greatest alternative,” he said.

The hard truth for chronic pain patients is that there is usually no such thing as a cure, said Cindy Steinberg, national director of policy and advocacy for the U.S. Pain Foundation.

She suffered a work injury herself that has led to years of pain, and hosts a support group in Massachusetts.

“To a person, the hundreds of people who have come to my groups over the years have had to see four or more physicians before they’ve been able to get help,” she said. It is often because insurance companies compensate doctors for 15-minute appointments, which is not enough time to build a comprehensive pain-management plan.

When patients do see specialists for therapies like acupuncture or meditation, they often have to pay out of pocket because their insurance doesn’t cover it.

“We’re talking a lot of people who are living with pain who have been neglected and not treated properly,” Steinberg said.

“I’m hoping that at least one positive outcome of this attention to opioids is that more research is done into the treatment of acute, sub-acute, and chronic pain.”