Tagged Missouri

Listen: Missouri Efforts Show How Hard It Is To Treat Pain Without Opioids

KHN Midwest correspondent Lauren Weber speaks with KBIA’s Sebastián Martínez Valdivia about the challenges Missouri faces in trying to treat chronic pain without opioids. Weber had reported that only about 500 of Missouri’s roughly 330,000 adult Medicaid beneficiaries used a new, alternative pain management plan to stem opioid overprescribing in the program’s first nine months. Meanwhile, 109,610 Missouri Medicaid patients received opioid prescriptions last year.

You can listen to the conversation on the KBIA website.

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Coronavirus Tests Public Health Infrastructure In The Heartland

JEFFERSON CITY, Mo. — Every weekday at noon since Jan. 27, the Missouri Department of Health and Senior Services Director Randall Williams gathers his outbreak response team for a meeting on coronavirus.

Missouri has yet to have a confirmed case of what officials are now calling COVID-19, but about 20 people statewide are being monitored for the novel viral infection originating from Wuhan, China. While 15 cases have been confirmed in the U.S. so far, tens of thousands of people have been infected worldwide and more than 1,300 have died. Global — and local — fears of the spread of the respiratory virus are fueling concerns about a lack of preparation in the U.S.

Missouri health department staff have been working overtime preparing for if, and when, the cases come by ensuring they have adequate supplies of non-expired protective gear like masks and planning how to trace the movements of those who have come in contact with potentially infected people.

They’re also helping set up coronavirus testing capabilities at a regional lab based here in the state capital to evaluate potential cases from Missouri, Kansas, Nebraska and Iowa. The U.S. Centers for Disease Control and Prevention has started shipping testing kits around the country.

Coronavirus may not require a front-line battle yet in places like Missouri as it does in states with confirmed cases, such as Washington, California, Illinois and Texas. But it’s still taxing public health officials in Missouri, which has one of the lowest levels in the nation for public health spending per person. And they, like health officials in other states, are stuck in the tricky position of trying not to be over- or underprepared for a potential public health crisis that may never come.

Missouri’s legislature is considering an additional $300,000 in emergency funding for events like coronavirus. This money is vital for responding to outbreaks in the state, Williams said, including more common concerns like mumps and measles or ongoing fights against hepatitis A and tuberculosis.

However, according to Williams, the legislature denied such an appeal for $300,000 last year.

“We are essentially like a fire department, right? People want us to be available when there’s a fire,” the director said. “But when there’s not a fire, they don’t really give a lot of thought to it.”

Limited Budget

As state officials gear up for possible problems from coronavirus, local health departments in Missouri are at a disadvantage because they have lost staff amid state budget cuts, according to Lindsey Baker, research director for the Missouri Budget Project, a nonprofit focused on public policy decisions.

Similar patterns hold true across the nation. Almost a quarter of local health department jobs have been lost since 2008, according to the National Association of County and City Health Officials, and a quarter of local health departments experienced budget cuts last year.

While federal funding has supplemented public health funding in Missouri, Baker said, the federal cash comes with strict rules on how it can be used.

Williams stressed that, despite Missouri’s limited budget, his state ranked in the top tier for emergency preparedness by Trust for America’s Health, a nonprofit advocacy group promoting public health.

Money notwithstanding, viruses like COVID-19 force the staff to work longer hours, according to state epidemiologist Dr. George Turabelidze, as the health department juggles its existing workload with pressing concerns.

“Everything else is happening — it’s not like we can switch, we have to do all this at once,” Turabelidze said.

Plus, he added, since this outbreak involves world travelers arriving at all times of the day, his staff has had to work weekends to track down where travelers have come from and whether they’ve had contact with infected people. For now, salaried staffers — who do not receive overtime — are expected to shoulder the extra load.

Even as they work extra hours, some routine health department matters such as onsite sewage inspections “get put in the back seat,” said Adam Crumbliss, chief director of Missouri’s Division of Community and Public Health.

If coronavirus reaches a pandemic level — in which it spreads worldwide — Crumbliss said the National Guard could be activated.

Relying On Existing Relationships And Stockpiles

Vital to any public health emergency response are the underlying relationships, stressed Paula Nickelson, the state’s program coordinator for health care system readiness. Knowing whom to call and having an established rapport with key health care providers such as the Missouri Hospital Association is critical during a crisis.

As is experience. Nickelson said the state’s response capabilities were tested and strengthened during a successful practice transport of a hypothetical Ebola patient from St. Louis to the University of Iowa in May.

Through that exercise, they learned that the material of their ISOPODs — portable, see-through isolation units that quarantine infected patients while allowing them to still see and speak to other people — was so thick it made it hard to hear those inside. Now, they are equipping them with walkie-talkies.

Another major question in recent days is a potential onslaught of shortages of protective medical equipment — everything from masks to latex gloves ― often manufactured in China. Nickelson said the state has assessed what materials are on hand.

“They’re fairly small amounts,” she said. “What we found over the course of a decade is that a lot of that stuff sits on the shelf, doesn’t necessarily get used, and so we’re better off to have just-in-time, vendor-managed processes in place.”

Still, Nickelson noted, that could become a problem for everyone if a pandemic occurs and those vendors become swamped with orders.

“This is by no means a sprint,” Crumbliss said. “This is a long wind race.”

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No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy

ST. LOUIS — Missouri began offering chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy for Medicaid patients in April, the latest state to try an alternative to opioids for those battling chronic pain.

Yet only about 500 of the state’s roughly 330,000 adult Medicaid users accessed the program through December, at a cost of $190,000, according to Josh Moore, the Missouri Medicaid pharmacy director. While the numbers may reflect an undercount because of lags in submitting claims, the jointly funded federal-state program known in the state as MO HealthNet is hitting just a fraction of possible patients so far.

Meanwhile, according to the state, opioids were still being doled out: 109,610 Missouri Medicaid patients of all age groups received opioid prescriptions last year.

The going has been slow, health experts said, because of a slew of barriers. Such treatments are more time-consuming and involved than simply getting a prescription. A limited number of providers offer alternative treatment options, especially to Medicaid patients. And perhaps the biggest problem? These therapies don’t seem to work for everyone.

The slow rollout highlights the overall challenges in implementing programs aimed at righting the ship on opioid abuse in Missouri — and nationwide. To be sure, from 2012 to 2019, the number of Missouri Medicaid patients prescribed opioid drugs fell by more than a third — and the quantity of opioids dispensed by Medicaid dropped by more than half.

Still, opioid overdoses killed an estimated 1,132 Missourians in 2018 and 46,802 Americans nationally, according to the latest data available. Progress to change that can be frustratingly slow.

“The opioids crisis we got into wasn’t born in a year,” Moore said. “To expect we’d get perfect results after a year would be incredibly optimistic.”

Despite limited data on the efficacy of alternative pain management plans, such efforts have become more accepted, especially following a summer report of pain management best practices from the U.S. Department of Health and Human Services. States such as Ohio and Oregon see them as one part of a menu of options aimed at curbing the opioid crisis.

St. Louis chiropractor Ross Mattox, an assistant professor at chiropractic school Logan University, sees both uninsured patients and those on Medicaid at the CareSTL clinic. He cheered Missouri’s decision to expand access, despite how long it took to get here.

“One of the most common things I heard from providers,” he said, “is ‘I want to send my patient to a chiropractor, but they don’t have the insurance. I don’t want to prescribe an opioid — I’d rather go a more conservative route — but that’s the only option I have.’”

And that can lead to the same tragic story: Someone gets addicted to opioids, runs out of a prescription and turns to the street before becoming another sad statistic.

“It all starts quite simply with back pain,” Mattox said.

Practical Barriers

While Missouri health care providers now have another tool besides prescribing opioids to patients with Medicaid, the multistep approaches required by alternative treatments create many more hoops than a pharmacy visit.

The physicians who recommend such treatments must support the option, and patients must agree. Then the patient must be able to find a provider who accepts Medicaid, get to the provider’s office even if far away and then undergo multiple, time-consuming therapies.

“After you see the chiropractor’s for one visit, it’s not like you’re cured from using opioids forever — it would take months and months and months,” Moore said.

The effort and cost that go into coordinating a care plan with multiple alternative pain therapies is another barrier.

“Covering a course of cheap opioid pills is different than trying to create a multidisciplinary individualized plan that may or may not work,” said Leo Beletsky, a professor of law and health sciences at Northeastern University in Boston, noting that the scientific evidence of the efficacy of such treatments is mixed.

And then there’s the reimbursement issue for the providers. Corry Meyers, an acupuncturist in suburban St. Louis, does not accept insurance in his practice. But he said other acupuncturists in Missouri debate whether to take advantage of the new Medicaid program, concerned the payment rates to providers will be too low to be worthwhile.

“It runs the gamut, as everyone agrees that these patients need it,” Meyers stressed. But he said many acupuncturists wonder: “Am I going to be able to stay open if I take Medicaid?”

Structural Issues 

While helpful, plans like Missouri’s don’t address the structural problems at the root of the opioid crisis, Beletsky said.

“Opioid overutilization or overprescribing is not just a crisis in and of itself; it’s a symptom of broader structural problems in the U.S. health care system,” he said. “Prescribers reached for opioids in larger and larger numbers not just because they were being fooled into doing so by these pharmaceutical companies, but because they work really well for a broad variety of ailments for which we’re not doing enough in terms of prevention and treatment.”

Fixing some of the core problems leading to opioid dependence — rural health care “deserts” and the impact of manual labor and obesity on chronic pain — requires much more than a treatment alternative, Beletsky said.

And no matter how many alternatives are offered, he said, opioids will remain a crucial medicine for some patients.

Furthermore, while alternative pain management therapies may lessen opioid prescriptions, they do not address exploding methamphetamine addiction or other addiction crises leading to overdoses nationwide — even as a flood of funds pours in from the national and state level to fight these crises.

The Show-Me State’s refusal to expand Medicaid coverage to more people under the Affordable Care Act also hampers overall progress, said Dr. Fred Rottnek, a family and addiction doctor who sits on the St. Louis Regional Health Commission as chair of the Provider Services Advisory Board.

“The problem is we relatively cover so few people in Missouri with Medicaid,” he said. “The denominator is so small that it doesn’t affect the numbers a whole lot.”

But providers like Mattox are happy that such alternative treatments are now an option, even if they’re available only for a limited audience.

He just wishes it had been done sooner.

“A lot of it has to do with politics and the slow gears of government,” he said. “Unfortunately, it’s taken people dying — it’s taken enough of a crisis for people to open their eyes and say, ‘Maybe there’s a better way to do this.’”

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