The opioid crisis: The links between national and state initiatives

By Taylor Walsh

Since late 2015, the nation’s response to the opioid addiction crisis has led to unprecedented changes by the primary professional medical organizations and standards bodies that author guidelines and recommendations for pain treatment. The movement to first-line chronic pain management— away from opioids and drugs-first to non-pharmacological and integrative treatment options—is nearly universally accepted as optimal at the national level, even as the practical matter of educating physicians and payers will take considerable energy and effort.

This unfolding response to the national public health crisis has also led to two important and intertwined trends:

1. The formation of unheard of collaborations at the national level among professional medical and policy organizations from both the conventional medical and the integrative health communities. The Inaugural Integrative Pain Care Policy Congress, held last October in San Diego, established a new imperative of working relationships among these participating organizations that now continue through the creation of working groups and plans for a second national congress in November in Boston.
2. A rekindling of state-based activism that emerged first in 2014 with the implementation of the Affordable Care Act (ACA) Section 2706, which was designed to prohibit private insurer discrimination against care providers who are licensed in their states. Those efforts, initially intended to expand reimbursement generally, ultimately evolved to meet a state’s particular opioid addiction treatment needs.

Early in 2018, a third factor emerged that could very well draw these national and state-level trends together: the newly formed Congressional Caucus for Integrative Health & Wellness.  At a first presentation in March on Capitol Hill, the Caucus was introduced by its co-chairs, Colorado representatives Mike Coffman (R) and Jared Polis (D). They noted that its purpose is to change the current approach of conventional care to proactively focus more on outcomes, prevention, and alternatives, as well as integrating those approaches into the healthcare system.  Both emphasized the need to put the “whole person” as the focus in terms of health outcomes.

The introductory session was organized at the request of Coffman and Polis by the Integrative Health Policy Consortium (IHPC), which has been informing Congress on issues related to complementary and integrative medicine and health since the early 2000s. IHPC will also manage the recruitment of additional members. An early and influential member is Congressman Tim Ryan (D) whose commitment to mindfulness and to addressing Ohio’s debilitating opioid condition is well-known.   

Congressional members who engage through the Caucus might well bring some cohesion between broad national efforts and those that have been in place in the states.  A good example of this potential can be seen in Rhode Island, where actions in recent years have gradually expanded access to integrative practitioners for patients.  The most recent of these:

• In 2018, a provider coalition, with the support of state Attorney General Peter Kilmartin, has introduced legislation (H 7499) that, “Requires health insurance companies to cover non-opioid treatments for pain which includes physical therapy, occupational therapy, massage therapy, acupuncture and oriental medicine.”
• In 2018, Rhode Island congressman David Cicilline (D) became one of the first U.S. congressmen to join the Congressional Caucus for Integrative Health & Wellness.
• In 2017, legislation passed that designated state licensure for Naturopathic physicians (NDs).
• In 2017 the private insurer practice of setting caps on chiropractors services (i.e., limited numbers of visits) was ended, taking effect April 1, 2018.

Those developments follow on previous initiatives in Rhode Island that also moved toward toward greater access to integrative treatments and providers:

• Delivering a Medicaid pilot program (2012-2015) whose whole healthcare framework was designed to reduce the costs of treating the state’s highest utilizers of services. Quite successful in terms of health outcomes and cost reductions, the pilot provided services including integrative therapies from state practitioners paid in part by Medicaid.
• Enacting legislation in 2015 that prohibited discrimination by private insurers against state-licensed healthcare providers.  This law was modeled on the provisions of Section 2706 of the Affordable Care Act.

This is an impressive set of primarily state-based actions, the most recent reflecting urgency for a state as hard-hit with the opioid crisis as is Rhode Island. With Rep. Cicilline now part of the new congressional caucus, and the state’s Attorney General advocating for new legislation affirming non-pharmacological pain management treatments, coordinated federal and state actions might move to a next level. 

The formation of the Caucus may also be consequential far beyond the immediate and essential demands for dealing with the opioid crisis.  During a presentation at the congressional caucus meeting in March, Benjamin Kligler, MD, longtime national leader in integrative medicine and now national director of the U.S. Department of Veterans Affairs’ (VA) Integrative Health Coordinating Center, presented on the VA’s new Whole Health Pathway, a robust program that puts in place a care paradigm centered, as Coffman and Polis called for, “more on prevention, more on alternatives …emphasizing the need to put the whole person as the focus.” 

Carefully nurtured and evolved within the VA’s own research enterprise and clinical network over more than six years, the Whole Health Pathway, Kligler reported, is being piloted in full-scale demo projects in each of the VA’s 18 regions that are served by 150 healthcare centers.  The model includes: 

• “Non-clinical” personal health planning
•  A wellbeing program that combines whole health coaching with health supporting modalities like tai chi and yoga
• Whole health primary care clinical services

As Kligler noted, the core approach of the Pathway can be seen in a simple shift in wording, from, “What’s the matter with you?” to “What matters to you?”  (Yes, that’ the Veterans Health Administration.)

The patient-reach of this program is expected to be prodigious: 100,000 or 30 percent of the patients who are served within those 18 VA regions. It is worth noting that specialists in some modalities, such as tai chi and yoga, are approved even though the modalities are not state-licensed.

This national VA healthcare program, beset by many issues, including a serious current challenge to its status as a public responsibility, will essentially bring its whole health paradigm into local communities across the country through its clinical network.  Although “closed” as a delivery system, the VA’s Pathway program could establish a model that can influence program and funding decisions at the state level, in particular where Medicaid programs can directly address the addiction epidemic with non-pharmacologic options.

The VA model arrives at a kind of threshold moment in the succession of integrative community efforts dating back to the 2000s to expand access to providers and their treatment options: to end insurer reimbursement discrimination against licensed providers (national and state), to advance whole health (“what matters to you?”) care models, to reduce the costs of treating chronic conditions, and to bring non-pharmacologic treatment options to the forefront of pain management and opioid addiction treatment. These efforts have created a formidable foundation on which state-national collaborations can expand, if there is a concerted effort to create them. 

The collaborations to watch this year will be the continued activities of the Integrative Pain Care Policy Congress and the progress that the Congressional Caucus for Integrative Health & Wellness makes signing up members of the House and Senate, particularly those representing states with existing initiatives on policy, legislation and programs directed to improvements in pain and opioid policy.

West Virginia for example.  At the end of March, Governor Jim Jacobs signed Senate Bill 273, the “Opioid Reduction Act” which includes this language:  

“When patients seek treatment for any of the myriad conditions that cause pain, a health care practitioner shall refer or prescribe to a patient any of the following treatment alternatives, based on the practitioner’s clinical judgment and the availability of the treatment, before starting a patient on an opioid: physical therapy, occupational therapy, acupuncture, massage therapy, 21 osteopathic manipulation, chronic pain management program, and chiropractic services.”

This is a significant advancement in modifying the therapeutic order for pain management.  It was the result of the work of a coalition of state-based physicians, physical therapists, and chiropractors, according to Chad Robinson, executive director of the West Virginia chiropractic society. Robinson was unaware of the congressional caucus, but felt that it would be of interest to the state’s congressional delegation, in particular Sen. Joe Manchin (D), who he says has been a “staunch” supporter of chiropractic and innovations for resolving the opioid menace in his state.

The West Virginia case is an example of the “one-off” successes that have taken place in some states over the last four or five years in Oregon, Rhode Island, Ohio, and Vermont.  A more sustained, accelerated movement for change may be possible by connecting state advocacy initiatives with new national resources such as the congressional caucus and the Integrative Pain Care Policy Congress.