HCR -- Understanding Opioid Use and Abuse

By John Ballard.

I follow Joe Paduda's blog and have linked it in the past because of his unique perspective of "managed care." Most readers see that term and keep reading without stopping to consider that ALL good medical care, properly understood, is managed, hopefully by a good doctor or team of other professionals, with the aim of making the patient better. Actually managed care, done right, is a reincarnation of the old H.M.O. idea.

Unfortunately, thanks to the avarice of for-profit insurance companies any mention of health maintenance organizations is met with disgust. The concept was introduced in the seventies but because medical claims are regarded as losses for accounting purposes, claims representatives in an effort to maximize corporate profits denied so many claims (some call it rationing) that HMO's received a bad image. A more recent variant, the PPO (preferred provider organization) is a variant of the same idea, as is the so-called ACO (accountable care organization) as defined by the Affordable Care Act, i.e. Obamacare.

Managed care, in this case, refers to a subcategory of health care not typically considered in most discussions of reform -- workers compensation. Unlike "consumer** driven" health care the object of workers compensation is to treat whatever medical problem is causing an employee to miss work and get him or her back on the job as soon as possible. Elaborate rules have evolved over time dealing with pre-existing conditions, liability and other complications not usually associated with what might be called retail medicine (my term, as opposed to wholesale medicine which only has one layer of costs), but in the final analysis workers compensation, properly used, is a textbook example of how best to treat someone in need of medical attention effectively and economically.

Regarding opioid abuse Paduda says at Managed Care Matters

A reader asked why this has become so important an issue. Several reasons.

1. Most claimants on opioids aren't going back to work driving the school bus, operating the printing press, or moving patients in the nursing home. Getting claimants off opioids is the first step to getting the claim closed.


2. Drug costs are going thru the roof, driven in large part by overuse of narcotics.


3. There's very little medical evidence to support the long-term use of opioids for individuals with musculoskeletal injuries. Yet many claimants are on opioids for more than three months.

Here's a couple takeaways to get you thinking...

• Among individuals 12 years or older in 2008-2009 who used pain relievers nonmedically in the past 12 months, 55.3% acquired the drug from a friend or relative; 17.6% reported that it was prescribed by a single physician


• Evaluating opioid dependence requires an understanding of the difference between addiction, tolerance, and physical dependence.


• the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, defines substance dependence, which equates with addiction, as a maladaptive pattern of substance use over a 12-month period with evidence of 3 or more of the following (anything here sound familiar?):

• Drug tolerance


• Withdrawal symptoms


• The amount or duration of use is greater than intended


• The patient repeatedly tries unsuccessfully to control or reduce substance use


• The patient spends much time using the substance, recovering from its effects, or trying to obtain it


• The patient reduces or abandons important work, social, or leisure activities because of substance use


• The patient continues to use the substance despite knowledge that it has caused ongoing physical or psychological problems

In other words not all drug problems are the result of intractible cases of substance abuse. There is no one-size-fits-all solution to this common medical problem 

Informed patients and their doctors owe it to themselves to understand what's wrong and look for the quickest and most economical way to deal with it. Patients should do their homework and not expect miracles from medical providers. And providers, owe it to themselves and their patients to do everything in their power to fix their medical problems as expeditiously and economically as possible.

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**I use scare quotes with "consumer-driven" since most discussions make no distinction among truly sick people (chronic or acute) and the worried well, that vast population of consumers made eager, like those who follow other fashions, to have nothing but the latest of everything. I sometimes wonder if some number of joint-replacements are the geriatric equivalent of cosmetic surgery.  Economically disadvantaged people do without them just as they never afford assisted living, modern hearing aids or root canals.

In the food business we recognized a customer category we called the carriage trade. It refers to that class of folks once driven about in carriages, distinguishing them from common folk who either walked or rode horseback. In retailing it can also refer to the Nouveau riche who may not have been to the manor born, but who have enough discretionary income to imitate those who were.

A marketing appeal to the carriage trade also magically appeals to a large number of customers who may not be able to afford to make the purchase but who can make the payments. Being able to make the payments is not the same as actually affording what the payments can buy as illustrated, in case we need reminding, by the housing bubble.

The same dynamic has been at work in health care for some time and we have yet to see what will happen when that bubble bursts.