“Doc, which one is the cheapest, because I know my pain pills are less than $5?” one of my patients asked recently when I suggested alternatives to taking a Tylenol with codeine tablet every day for low back pain.

I was offering him the option of trying a different type of medication, either Cymbalta or Lyrica, both approved to treat chronic pain, and neither considered as dangerous as opioids. But he was most interested in how much this might cost. There was no guarantee either would work, and if they were expensive, he said he would rather stick to what always worked in the past.

According to the National Institute of Drug Abuse, 21% to 29% of people who are prescribed opioid medications misuse their prescription. The entire medical community has been put on high alert to avoid the use of high doses of opioid medications and to consider transitioning patients onto safer medications when clinically appropriate.

In 2017, Hawaii’s Senate Bill 505 required opioid prescribers to check the Prescription Drug Monitoring Program website to see if patients were also getting them elsewhere.

Although burdensome, this has resulted in closer scrutiny of the narcotic pills given for any type of pain. Combinations of these and another group, benzodiazepines, have been proven to be deadly. Many patients agree that they would like to take less controlled medication, and have asked about alternatives. Providers have been encouraged to look at other options, and guidelines have been developed by the federal Centers for Disease Control and Prevention on the proper use of opioids.

But many of these alternative treatments cost a lot more than a generic opioid prescription.

Shouldn’t these cost the same or less than potentially addictive opioids?

Studies have shown that medications like ibuprofen and acetaminophen are relatively good for relieving mild to moderate pain. These medications are also generic and not likely to cost a lot for either patients or insurance companies. Other options include prescription medications such as Cymbalta, Lyrica and the generic nortriptyline or gabapentin. These could range in copay from $5 to $75 depending on insurance coverage.

Should the cheapest medication be the opioid that we are trying to restrict? Should any non-opioid prescription for chronic pain be covered for a copay of little to nothing to encourage people to choose the safer option?

If patients are willing to reduce their opioid use, what other treatment options could be provided at no to low cost?

Options such as physical therapy have proven extremely effective, but copays for each session may make this safe alternative cost prohibitive as well. Massage is not a covered benefit for some insurance plans, adding to the cost for patients dealing with discomfort. Acupuncture and chiropractic care likewise often require the patient to pay the full cost.

The National Institutes of Health created the National Center for Complementary and Integrative Health to investigate whether alternative treatments might provide pain relief for a variety of medical conditions. Although the reports for all treatments are mixed, studies show some evidence of effective treatment for conditions such as back pain.

Lowering the cost of these therapies just makes sense, considering the overall cost to society for the treatment of opioid addiction.

What if all non-opioid treatments were covered for everyone with certain diagnoses that are usually treated by pain pills? For patients who chose to use alternative prescription medications, the cost could be minimized, encouraging the use of these safer treatments.

Patients already on opioids might need an incentive for trying to lower their doses. Additional coverage could be provided for the alternative approaches, including physical therapy, massage, chiropractic care and more.

Lowering the cost of these therapies just makes sense, considering the overall cost to society for the treatment of opioid addiction.

Alternatively, increasing the cost of the opioids could work, but the goal is not to enrich pharmaceutical companies or create a greater demand for illegal substitutes for opioid medications.

Improving insurance coverage for non-opioid treatments is a step in the right direction. Making these options free might cost more in the short term, but help reduce the number of people on these dangerous medications in the future.

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