An Alternative Approach to Pain Management

 
This prevalence of pain is occurring as we face a widespread opioid epidemic in U.S. 
That is why UnitedHealthcare advocates for alternative treatment options for common pain conditions, in accordance with clinical guidelines. While these options may not be appropriate in all clinical situations, we do encourage members and their doctors to conisder non-pharmacologic and non-opioid alternatives when deciding on the best course of treatment for chronic pain.

By the numbers:

  • 100 million American adults are affected by chronic pain, more people than diabetes, heart disease and concer combined
  • Every 13 minutes somone in the U.S. dies from an opioid overdose
  • 2 million Americans are estimated to have a substance use disorder with prescription painkillers
  • Nearly 250 million opioids were dispensed in 2013 - enough for every U.S. adult to have a bottle of pills

Reducing Reliance on long-acting opioids.

Opioids are drugs that act on the nervous system and are commonly used to treat pain. Clinical guidelines promote the use of non-pharmacologic and non-opioid treatment alternatives before using opioids, because these powerful drugs come with high risk of abuse and dependence.

The likelihood for chronic opioid use increases after the third day of use and rises rapidly thereafter,12  and misuse or dependence on opioids can lead to addiction to more powerful illicit drugs.

UnitedHealthcare is committed to reducing our nation's reliance on opioids.

  • 19%  drop in long-acting opioid use since January 2017 by UnitedHealthcare members.
  • 17% decrease in the average daily morphine equivalent does (MED), thanks to prior authorizations to apply CDC guidelines.

Non-pharmacologic treatment alternatives1
Before considering prescription drugs for the treatment of pain, it’s important to first explore the use of a non-pharmacologic treatment, or an approach without medication. An effective pain treatment plan combines non-pharmacologic alternatives with counseling, exercise and other lifestyle changes.

Non-pharmacologic examples include:2

  • For acute or subacute low back pain:3
    Superficial heat, massage, acupuncture or spinal manipulation, yoga or pilates
  • For chronic low back pain:3
    Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, pilates, motor control exercise or progressive relaxation
  • For neuropathic pain and fibromyalgia:
    Electrical nerve stimulation for diabetic neuropathy,4 physical therapy, yoga, pilates, cognitive behavioral therapy or multimodal rehabilitative services5

Individuals are encouraged to review their benefits coverage information as a person's coverage for these types of therapies may vary based upon plan design and/or employer.

Non-opioid pain medications1
CDC guidelines recommend the consideration of non-opioid medications before an opioid medication is prescribed for pain management.11 For example, over-the-counter (OTC) medications, such as acetaminophen or ibuprofen, are usually tried first for headaches, muscle pain, arthritic pain and several other conditions. The chart below is not a complete list, and we always reccomend discussing pain relief options with your physician.

Non-opioid examples include:2

 Type

 Description

 Examples

 Over-the-counter (OTC)
 pain relief

 OTC medications are usually tried first    
 for headaches, musculoskeletal pain,
 arthritic pain and several other
 conditions.  

 Acetaminophen,
 ibuprofen, naproxen

 Prescription
 nonsteroidal anti-
 inflammatory drugs
 (NSAID)

 These medications are effective for
 treating inflammatory pain or pain
 arising from stimulation of nerve cells.
 NSAIDs are a first-line option for low-
 back pain. Several oral and topical
 products are available. 

 Ibuprofen, naproxen,
 meloxicam,
 celecoxib

 Anticonvulsants

 Gabapentin is used to treat neuropathic
 pain (pain that develops when the
 nervous system is not working
 properly) and can be used as an initial
 treatment for diabetic neuropathy.
 Lyrica is a first-line option for
 neuropathic pain and fibromyalgia. 

 Gabapentin (generic
 Neurontin), Lyrica
 (pregabalin)

 Topical pain relief
 creams

 These can be used for neuropathic or
 muscle/join pain. 

 A variety of topical
 products exist. 

 Skeletal muscle
 relaxants

 

 Skeletal muscle relaxants or NSAIDs
 can be considered for treating acute or
 subacute low-back pain before
 considering other pharmacologic
 options. 

 Baclofen,
 cyclobenzaprine,
 tizanidine 

 Medications
 administered by a health
 care provider

 A variety of medications can be
 administered in a physician’s office to
 treat inflammatory, musculoskeletal,
 neuropathic and other types of pain. 

 Cortisone injection,
 nerve block

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References:
1. Member benefit coverage varies. Please refer to plan- specific information for current coverage information. UnitedHealthcare Community Plan Prescription Drug Lists and coverage vary by state due to each state Medicaid regulations.
2. Some of the recommended alternative medications listed above should be avoided and/or used with extra caution in in the elderly population. Alternatives aren’t intended to replace a clinician’s clinical judgment.
3. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017; 166(7):514-530.
4. Bril V, England J, Franklin GM, et al. Evidence-based guideline: treatment of painful diabetic neuropathy. Neurology. 2011;76(20):1758-1765.
5. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheumatic Dis. 2017;76:318-328.
6.  Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011. Accessed online 02/02/18: http://books.nap.edu/openbook.php?record_id=13172&page=1.
7. The American Academy of Pain Medicine. AAPM Facts and Figures on Pain. Accessed online 02/02/18: http://www.painmed.org/patientcenter/facts_on_pain.aspx
8. Centers for Disease Control and Prevention. Opioid Overdose, Understanding the Epidemic. Available at: https://www.cdc.gov/drugoverdose/epidemic/index.html
9. Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Accessed online 02/02/18: https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm
10. IMS Health, National Audit (NPATM). Cited in internal document: Preliminary Update on Opioid Pain Reliever (OPR) Prescription Rates Nationally and by State: 2010-2013. URL: https://www.cdc.gov/drugoverdose/opioids/prescribed.html
11. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315:1624-45.
12. National Opioids Crisis. Department of Health and Human Services. Available at https://www.hhs.gov/opioids/