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Chicken or the egg

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Terri Lewis
Terri Lewis

The document discusses trends in chronic pain, disability, and medical treatment in the United States from 2000-2013. It notes that the number of people receiving disability benefits for musculoskeletal disorders increased greatly in this period. Opioid prescriptions increased to over 200 million in 2013, with over 16,000 overdose deaths. Spinal injections also increased substantially, though evidence suggests they only provide short-term relief and no long-term benefits. The aging population and rise in chronic illnesses means these trends will likely continue increasing pressure on the healthcare system.

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Chronic PainAddiction Treatment Community Leadership 12/10/2015 copyright Terri A. Lewis PhD 1
On 1/24/2015 Sen.Rand Paul (KY) claimed that over half of the people on disability are either anxious or their back hurts. Lets look at the reported facts using the issue of spine health, which consumes a large portion of public resources Disability related to spine health, with comorbid conditions and negative economic impact has exploded from the year 2000. Men are affected only a little more than women. In 2013, 207 mil prescriptions were written for Opiods leading to 44,000 prescription related deaths and16,025 overdose deaths (.0079%) (CDC.gov) In 2014, 3,122,917 persons (31.2% of total) were on the SSDI rolls for musculoskeletal and connective tissue disorders (SSA.gov, 2015, November) In 2014, 8 mil prescriptions were written for the Medicare population for opioids (CMS.gov Opioid tracking tool) In 2014, the rate of interventional pain management procedures was 156%/100,000 Medicare beneficiaries, an increase of 236% from 2000 for a total estimated cost of $35bil Over half of the people on disability are either anxious or their back hurts (1/24/2015) 12/10/2015 copyright Terri A. Lewis PhD 2
In2013,self-harmranked10thamongallcausesfordeathintheUSA 41,149people(CDC.gov). In 2014, 31.2% of approvals for SSDI were due to musculoskeletal injuries, average age of 53 yrs, avg mo benefit $1,165 (SSA.gov) Onset of disability must render the person unable to earn $1090/mo in the national economy.Interventional procedures increased by 236% In 2013, 207 mil prescriptions were written for opioids, 16,025 overdose deaths (.0079%) Persons aged 45-64 have at least 1 major health condition, by 65, 5 or more major health conditions that will be present @ death (NIH.gov) 150,572 patients aged 0-59 received 262,301 epidural injections in 2012 171 mil Americans will have 1-5 Chronic illnesses 50 % populati on reaches 65 yrs of age 12/10/2015 copyright Terri A. Lewis PhD 3
12/10/2015 copyright Terri A. Lewis PhD 4
Utilization of Epidural Injections 2000 - 2013 12/10/2015 copyright Terri A. Lewis PhD 5
Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health Credit: National Prescription Audit 12/10/2015 copyright Terri A. Lewis PhD 6
https://www.ssa.gov/polic y/docs/statcomps/di_asr/ 2014/di_asr14.pdf From 2000 2013, the annual growth rate for spinal interventional techniques = 11.4%; During the same period- Interlaminar injections grew 36% Transforaminal injections grew 583% or 19.1% annually Whether these NONPHARMACOLOGICAL procedures have the desired impact on preserving function or reducing disability is QUESTIONABLE at best. Whether these should be relied upon as an alternative to OPIOIDs is also QUESTIONABLE at best. 12/10/2015 copyright Terri A. Lewis PhD 7
ESIs offer short term benefit (if any benefit at all) for chronic pain Epidural corticosteroid injections for radiculopathy are associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits are small and not sustained, and there is no effect on the long term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or non radicular back pain, and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate the effectiveness of sacroiliac joint corticosteroid injections. (AHRQ, 2015, March 20) 12/10/2015 copyright Terri A. Lewis PhD 8
What Can We Observe from 2000 - 2013? Millions of dollars are spent on procedures that have at best only short term effectiveness Interventional services among persons < 65 grew at a rate of 63.9% from 2000 - 2013 Interventional services grew at a population rate of 236%, advancing even as Medicare utilization is growing among baby boomers Reports of patient harm have steadily increased for mishaps and serious adverse events from 100,000 (1999) to 400,000 (2014) persons affected per year Average age of permanent disability = 53 yrs of age for musculoskeletal disorders, a premature economic loss to individuals and families of 13 work years We can characterize this phenomena and measure it by looking at entered disability program statistics 12/10/2015 copyright Terri A. Lewis PhD 9
There Are Too Few Nonpharmacological Tools Available to Physicians & Patients for Reduction of Chronic Pain Epidural injections are the leading nonpharmacological method used for the short term treatment of persons with spinal and joint pain resulting from a variety of causes. Is there a relationship between the onset of spinal related disability, epidural injections, spinal surgeries, and opioid prescribing? Available data raises the question about whether the growth of epidural injections, when compared to the growth of musculoskeletal injury, has any effect on reduction of disability or reduction of prescribing for opioids. If ESIs contribute no long term benefit, and have documented harms, why havent we called for their reduced use? Why arent we at least as concerned about the lack of effectiveness of epidural injections for chronic pain as we are about opioid use or misuse? 12/10/2015 copyright Terri A. Lewis PhD 10
Are we Having the Right Conversation? By 2025, the average age of persons in the United States will be 65 (census.gov) Age related chronic diseases with associated pain disorders will increase, not decrease (nih.gov) requiring new treatment models While 31.2% of persons receiving disability benefits reflect musculoskeletal disorders comorbid with other illnesses and injuries, the balance reflect a broad number of other life limiting health conditions that contribute to conditions of chronic pain which respond poorly to surgical interventions and pharmaceutical treatments if at all. The addiction treatment model is NOT the model we should use to interpret the future direction for the care and treatment of chronic pain and disability for an aging population. The integrated biopsychosocial model has yet to be implemented or funded by our health care system our failure to act will come home to roost. 12/10/2015 copyright Terri A. Lewis PhD 11
145 million Americans live with a chronic health condition; this figure will increase 1%/yr. through 2030 to 171 mil persons Almost half of all people with chronic illness have multiple conditions. Current community systems have many deficiencies in current management of chronic diseases. These deficiencies include: Inadequately trained practitioners not following established practice guidelines Lack of care coordination Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their illnesses Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible. 12/10/2015 copyright Terri A. Lewis PhD 12
Chicken? 12/10/2015 copyright Terri A. Lewis PhD 13
For persons with chronic pain and illness America's health care system is neither healthy, caring, nor a system. Walter Cronkite (11/4/1916 - 7/17/2009) 12/10/2015 copyright Terri A. Lewis PhD 14
Sources Case, A. & Deaton, A. (2015, Aug 22). Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century, Woodrow Wilson School of Public and International Affairs and Department of Economics, Princeton University, Princeton, NJ 08544 Chou,R., Hashimoto, R., Friedly, J., Fu, R., ana, T., Sullivan, S., Bougatsos, C., Jarvik, J. (2015, March 20). Technology Assessment: Pain Management Injection Therapies for Low Back Pain, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, Maryland 20850 Irwin, A (05/10/2015). Why Heroin Overdoses Are Rising and How We Can Prevent Them, Retrieved from http://www.huffingtonpost.com/amos-irwin/why-heroin- overdoses- Manchikanti, L., Pampati,V. . Falco, & Hirsch, J.A. (2015). An Updated Assessment of Utilization of Interventional Pain Management Techniques in the Medicare Population: 2000 2013, Pain Physician, 18: E115-E127 ISSN 2150-1149 Social Security Administration Office of Retirement and Disability Policy (2015). Tables 69 74 Outcomes of Applications for Disability Benefits. Retrieved from https://www.ssa.gov/policy/docs/statcomps/ssi_asr/2011/sect10.html Social Security Administration Office of Retirement and Disability Policy (2015). Annual Statistical Report on the Social Security Disability Insurance Program, 2014: Highlights. Retrieved from https://www.ssa.gov/policy/docs/statcomps/di_asr/2014/di_asr14.pdf United States Department of Commerce (n.d.) https://www.census.gov/population/international/files/97agewc.pdf Lewis, L. (2015, February 2). Budget seeks to Address Prescription Drug Abuse. TRNS online, Retrieved from http://www.talkradionews.com/health/2015/02/02/budget-seeks-address-prescription-drug- abuse.html 12/10/2015 copyright Terri A. Lewis PhD 15

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Chicken or the egg

  • 2. On 1/24/2015 Sen.Rand Paul (KY) claimed that over half of the people on disability are either anxious or their back hurts. Lets look at the reported facts using the issue of spine health, which consumes a large portion of public resources Disability related to spine health, with comorbid conditions and negative economic impact has exploded from the year 2000. Men are affected only a little more than women. In 2013, 207 mil prescriptions were written for Opiods leading to 44,000 prescription related deaths and16,025 overdose deaths (.0079%) (CDC.gov) In 2014, 3,122,917 persons (31.2% of total) were on the SSDI rolls for musculoskeletal and connective tissue disorders (SSA.gov, 2015, November) In 2014, 8 mil prescriptions were written for the Medicare population for opioids (CMS.gov Opioid tracking tool) In 2014, the rate of interventional pain management procedures was 156%/100,000 Medicare beneficiaries, an increase of 236% from 2000 for a total estimated cost of $35bil Over half of the people on disability are either anxious or their back hurts (1/24/2015) 12/10/2015 copyright Terri A. Lewis PhD 2
  • 3. In2013,self-harmranked10thamongallcausesfordeathintheUSA 41,149people(CDC.gov). In 2014, 31.2% of approvals for SSDI were due to musculoskeletal injuries, average age of 53 yrs, avg mo benefit $1,165 (SSA.gov) Onset of disability must render the person unable to earn $1090/mo in the national economy.Interventional procedures increased by 236% In 2013, 207 mil prescriptions were written for opioids, 16,025 overdose deaths (.0079%) Persons aged 45-64 have at least 1 major health condition, by 65, 5 or more major health conditions that will be present @ death (NIH.gov) 150,572 patients aged 0-59 received 262,301 epidural injections in 2012 171 mil Americans will have 1-5 Chronic illnesses 50 % populati on reaches 65 yrs of age 12/10/2015 copyright Terri A. Lewis PhD 3
  • 4. 12/10/2015 copyright Terri A. Lewis PhD 4
  • 5. Utilization of Epidural Injections 2000 - 2013 12/10/2015 copyright Terri A. Lewis PhD 5
  • 6. Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health Credit: National Prescription Audit 12/10/2015 copyright Terri A. Lewis PhD 6
  • 7. https://www.ssa.gov/polic y/docs/statcomps/di_asr/ 2014/di_asr14.pdf From 2000 2013, the annual growth rate for spinal interventional techniques = 11.4%; During the same period- Interlaminar injections grew 36% Transforaminal injections grew 583% or 19.1% annually Whether these NONPHARMACOLOGICAL procedures have the desired impact on preserving function or reducing disability is QUESTIONABLE at best. Whether these should be relied upon as an alternative to OPIOIDs is also QUESTIONABLE at best. 12/10/2015 copyright Terri A. Lewis PhD 7
  • 8. ESIs offer short term benefit (if any benefit at all) for chronic pain Epidural corticosteroid injections for radiculopathy are associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits are small and not sustained, and there is no effect on the long term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or non radicular back pain, and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate the effectiveness of sacroiliac joint corticosteroid injections. (AHRQ, 2015, March 20) 12/10/2015 copyright Terri A. Lewis PhD 8
  • 9. What Can We Observe from 2000 - 2013? Millions of dollars are spent on procedures that have at best only short term effectiveness Interventional services among persons < 65 grew at a rate of 63.9% from 2000 - 2013 Interventional services grew at a population rate of 236%, advancing even as Medicare utilization is growing among baby boomers Reports of patient harm have steadily increased for mishaps and serious adverse events from 100,000 (1999) to 400,000 (2014) persons affected per year Average age of permanent disability = 53 yrs of age for musculoskeletal disorders, a premature economic loss to individuals and families of 13 work years We can characterize this phenomena and measure it by looking at entered disability program statistics 12/10/2015 copyright Terri A. Lewis PhD 9
  • 10. There Are Too Few Nonpharmacological Tools Available to Physicians & Patients for Reduction of Chronic Pain Epidural injections are the leading nonpharmacological method used for the short term treatment of persons with spinal and joint pain resulting from a variety of causes. Is there a relationship between the onset of spinal related disability, epidural injections, spinal surgeries, and opioid prescribing? Available data raises the question about whether the growth of epidural injections, when compared to the growth of musculoskeletal injury, has any effect on reduction of disability or reduction of prescribing for opioids. If ESIs contribute no long term benefit, and have documented harms, why havent we called for their reduced use? Why arent we at least as concerned about the lack of effectiveness of epidural injections for chronic pain as we are about opioid use or misuse? 12/10/2015 copyright Terri A. Lewis PhD 10
  • 11. Are we Having the Right Conversation? By 2025, the average age of persons in the United States will be 65 (census.gov) Age related chronic diseases with associated pain disorders will increase, not decrease (nih.gov) requiring new treatment models While 31.2% of persons receiving disability benefits reflect musculoskeletal disorders comorbid with other illnesses and injuries, the balance reflect a broad number of other life limiting health conditions that contribute to conditions of chronic pain which respond poorly to surgical interventions and pharmaceutical treatments if at all. The addiction treatment model is NOT the model we should use to interpret the future direction for the care and treatment of chronic pain and disability for an aging population. The integrated biopsychosocial model has yet to be implemented or funded by our health care system our failure to act will come home to roost. 12/10/2015 copyright Terri A. Lewis PhD 11
  • 12. 145 million Americans live with a chronic health condition; this figure will increase 1%/yr. through 2030 to 171 mil persons Almost half of all people with chronic illness have multiple conditions. Current community systems have many deficiencies in current management of chronic diseases. These deficiencies include: Inadequately trained practitioners not following established practice guidelines Lack of care coordination Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their illnesses Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible. 12/10/2015 copyright Terri A. Lewis PhD 12
  • 14. For persons with chronic pain and illness America's health care system is neither healthy, caring, nor a system. Walter Cronkite (11/4/1916 - 7/17/2009) 12/10/2015 copyright Terri A. Lewis PhD 14
  • 15. Sources Case, A. & Deaton, A. (2015, Aug 22). Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century, Woodrow Wilson School of Public and International Affairs and Department of Economics, Princeton University, Princeton, NJ 08544 Chou,R., Hashimoto, R., Friedly, J., Fu, R., ana, T., Sullivan, S., Bougatsos, C., Jarvik, J. (2015, March 20). Technology Assessment: Pain Management Injection Therapies for Low Back Pain, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, Maryland 20850 Irwin, A (05/10/2015). Why Heroin Overdoses Are Rising and How We Can Prevent Them, Retrieved from http://www.huffingtonpost.com/amos-irwin/why-heroin- overdoses- Manchikanti, L., Pampati,V. . Falco, & Hirsch, J.A. (2015). An Updated Assessment of Utilization of Interventional Pain Management Techniques in the Medicare Population: 2000 2013, Pain Physician, 18: E115-E127 ISSN 2150-1149 Social Security Administration Office of Retirement and Disability Policy (2015). Tables 69 74 Outcomes of Applications for Disability Benefits. Retrieved from https://www.ssa.gov/policy/docs/statcomps/ssi_asr/2011/sect10.html Social Security Administration Office of Retirement and Disability Policy (2015). Annual Statistical Report on the Social Security Disability Insurance Program, 2014: Highlights. Retrieved from https://www.ssa.gov/policy/docs/statcomps/di_asr/2014/di_asr14.pdf United States Department of Commerce (n.d.) https://www.census.gov/population/international/files/97agewc.pdf Lewis, L. (2015, February 2). Budget seeks to Address Prescription Drug Abuse. TRNS online, Retrieved from http://www.talkradionews.com/health/2015/02/02/budget-seeks-address-prescription-drug- abuse.html 12/10/2015 copyright Terri A. Lewis PhD 15