Amit Shah, the chief medical officer at CareOregon, once had a patient so beset with chronic pain that his initial goal was just to get her to walk to the mailbox. Once she could do that, he wanted her to walk a little farther each day until she could make it around the block.
What Shah didn’t want to do was prescribe her a potentially addictive painkiller. Instead, he prescribed what amounted to self-administered physical therapy -- in this case, the simple act of walking. It worked. The patient eventually made it around the block.
It isn’t news that the medical community is grappling with how to reduce dependence on prescription painkillers. As the opioid epidemic remains front and center, some places are experimenting with alternative therapies such as acupuncture, massage and yoga. Oregon is pioneering the practice, mandating not only that insurance providers cover these therapies but also that they be given priority over prescriptions.
Oregon’s emphasis on alternative therapies originated with CareOregon, a nonprofit that contracts with the state’s Medicaid and Medicare programs. Several years ago, it funded its own non-medication pain clinic in a small coastal town, offering physical therapy, peer-group support and behavioral health services to patients with chronic back pain. The results were encouraging. The Oregon Health Plan, the agency that administers Medicaid and Medicare in the state, eventually moved to cover services including acupuncture, chiropractic care and physical therapy for patients across the state.
It’s been less than two years since those changes went into effect, and Shah says that not only are people using the alternative therapies but also that opioid prescriptions are down as a result. Nevertheless, there’s a major barrier to widespread adoption of these therapies. “There’s not great evidence for a lot of them,” says Kelly Pfeifer, director of High-Value Care at the nonprofit California Health Care Foundation. “Health plans will generally only cover things with a lot of evidence.”
Studies of alternative therapies for chronic pain -- particularly back pain -- aren’t conclusive. Research on the effectiveness of acupuncture and yoga in alleviating chronic pain is spotty at best, and chiropractic care and massage have been shown to work well only for short episodes of back pain. Still, Pfeifer and her team think these therapies have promise, and Medi-Cal, California’s Medicaid program, now covers acupuncture and chiropractic services.
Shah acknowledges that rolling out some of these treatments might be easier in a place such as Portland, “where there’s an acupuncture clinic on every corner.” But the fact that a smaller community might not have every kind of alternative therapy readily available doesn’t mean that there aren’t opportunities. “Sometimes it can be something as simple as a pool membership,” Shah says, mentioning a patient who felt better after sitting in a warm pool every day.
Despite the dearth of conclusive research, Shah is convinced that opioids aren’t the right choice for the majority of chronic pain sufferers. But doctors and health experts acknowledge that there are complex patients and conditions where strong painkillers are needed. They just think that necessity has been overestimated. “It’s really easy to prescribe opioids,” says Pfeifer. “We’re asking doctors now to do hard stuff. They want to help patients, but it takes effort because we’ve been such a pill-popping country. I like to describe it like implementing hand-washing in surgery. That took a generation.”
*This story has been updated to clarify that the California Health Care Foundation is not responsible for Medi-Cal covering acupuncture and chiropractic services.