Non-Opioid Directives and Coverage of Non-Opioid Therapy

Non-Opioid Directives and Coverage of Non-Opioid Therapy

This paper will discuss advocacy for Ohio Senate Bill 51 which aims to establish a Non-Opioid Directive and coverage of evidence-based Non-Opioid therapies by certain insurance carriers (S.B. 51, 2019).  This Bill was chosen due to the catastrophic opioid crisis that currently exists in the State of Ohio.  An overview of healthcare policy and advocacy, identification and solution of the healthcare policy concern, and identification of an elected official to present this information to will be explored.

Overview of Healthcare Policy

According to the World Health Organization ([WHO], 2019), “Health policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society.”  Government policies are in place to serve as regulatory guidelines within many different industries including healthcare.  Policy and law provide the framework to dictate the behavior of individuals and organizations in order to improve how healthcare is delivered resulting in better public health (Teitelbaum & Wilensky, 2017).  

Nurses work on the frontline within all health care settings. This provides nurses with the unique opportunity to recognize what best practices are not working and the knowledge to develop new policies in order to improve patient care, patient safety, and ultimately the health of the community. As stated by The American Nurses Association (ANA) Code of Ethics, nurses in all roles and settings should strive to advance their profession by conducting research and scholarly inquiry, developing professional standards and generating nursing and health policy (American Nurses Association, 2015).

Patient advocacy is one way in which nurses can execute the provisions outlined by the ANA’s Code of Ethics.  Merriam-Webster (2019) defines an advocate as one who pleads the cause of another; specifically: one who pleads the cause of another before a tribunal or judicial court.  Since nurses spend the most time with patients, we have insight into what is working well and what is not. Our experiences with patient care provide us with the information to identify problems within our current healthcare system.

If we then share those experiences and our insight with elected and/or public officials, we can advocate for our patients and get involved in the policy-making process.  Advanced Practice Nurses have the knowledge and experience to promote health, advocate for increased access to care, reduce health disparities and help shape the health delivery system by getting involved in policy processes (American Associations of Colleges of Nursing, 2011).

Identification of Healthcare Concerns

The healthcare concern I have chosen to address is the current opioid crisis in the State of Ohio.  While the Opioid crisis is present across the United States, it has hit Ohio especially hard.  Ohio had the second highest rate of opioid related overdose deaths in the United States in 2017 with 947 deaths attributed to prescription drugs and 3,523 deaths attributed to synthetic opioids such as fentanyl.  Heroin-related deaths also increased from 139 in 2012 to 3,523 in 2017 (The National Institute on Drug Abuse, 2019).

So of course we ask, how did we get here?  In the 1990s, pain was implemented as the fifth vital sign in an effort to improve the treatment of pain. Unfortunately, this leads to physicians overprescribing opioids for pain (Anson, 2016).  Of course, this was supported by the pharmaceutical companies who assured the medical community that opioid therapy was safe for their patients and the patients would not become addicted. Extended-release oxycodone (OxyContin) was introduced in 1996 with the manufacturer claiming that it was not as addictive.

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As opioid medications became more difficult to prescribe and dispense, the synthetic opioid Fentanyl gained popularity due to its potency and decreased manufacturing cost (National Institute on Drug Abuse, 2019).  Over time of course we learned that patients were becoming addicted and began using opioids to self-medicate. At the start, these medications could be obtained quite easily.

Over time as we learned that misuse and addiction had become a problem, policies were changed making it difficult for patients to obtain the number of medications they had become accustomed to taking.  This led to patients “doctor shopping” and visiting multiple emergency rooms in an effort to receive prescriptions from multiple providers (National Institute on Drug Abuse, 2015).  With the implementation of prescribing limits and the use of Prescription Monitoring Programs, patients started switching to illicit drugs like heroin which is cheap and can be easily obtained (Centers for Disease Control and Prevention, 2014).

The opioid crisis affects a broad spectrum of users.  It is present in the city, the suburbs, and rural areas.  There is no discrimination in regards to age, demographic, social status, or race.  The switch from prescription opioids to illicit drugs comes with deadly consequences.  Street drugs do not provide a label with the contents which makes them extremely dangerous and oftentimes deadly.  Heroin, fentanyl, and carfentanil can be immediately deadly.  A user may buy what they were told is heroin and it may actually be fentanyl which can cause death instantly.  The same thing can happen with heroin that is too pure, carfentanil, or synthetic drug versions which is certainly evident in the overdose rates (Higgs, 2016).

Solutions to Healthcare Concerns

Although often used as the first line of treatment, opioid use has not been shown to be effective in the treatment of chronic pain. (Schneiderhan, Clauw & Schwenk, 2017).  Evidence suggests that-opioid therapies and treatment options are often much more effective and do not run the risk of addiction.  However, non-opioid treatment options are often not covered treatment options by insurance and patients cannot afford the out-of-pocket expense.  For example, Ohio Medicaid does not cover some non-pharmacologic evidence-based therapies.

Another issue is that Ohio healthcare providers are not properly trained in regards to appropriate pain management or addiction because the training is not required.  This more than likely limits the use of non-opioid therapies along with non-pharmacologic methods (Stevens & Akah, 2018).  Due to these facts, the healthcare solution that I have chosen to advocate for is the establishment of non-opioid directives with coverage of non-opioid therapy, Senate Bill 51 (S.B. 51, 2019).  The State of Ohio is in a serious opioid crisis and I believe the passage of this bill will make a difference.

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There is a multitude of alternative therapies available for pain management that are often not utilized.  Non-pharmacologic therapies such as acupuncture or yoga may decrease pain.  Known barriers to these treatment options include limited access to these services and poor reimbursement.  The patient may also be opposed to these treatment options and demand pharmacologic treatment including opioids if they have had any amount of pain relief from their use in the past.  The patient resistance may also be due to a knowledge deficit or lack of encouragement for other treatment options by their providers Schneiderhan, Clauw, & Schwenk, 2017).

If Senate Bill 51 was passed, health insurance companies would be required to provide coverage for “evidence-based therapies that do not require the use of opioid analgesics in the treatment of pain.”  The bill also proposes the development of a non-opioid Directive form within one year of its effective date.  The non-opioid Directive form would specify that the patient does not wish to be offered, administered, prescribed, or provided an opioid analgesic as means of therapy.  If a non-opioid Directive was in place it would require prescribers to offer other means of therapy before treatment with an opioid analgesic occurs (S.B. 51, 2019).

The implementation of S.B. 51 would require education for providers as well as patients and families.  Healthcare providers would need to increase the utilization of non-opioid evidence-based pain management options and would need to provide patient education regarding these non-opioid therapies. This would first require education for the providers along with improved insurance coverage.

Non-Opioid Directives And Coverage Of Non-Opioid TherapyProviders should also be required to complete mandatory continuing education with regard to proper pain management (Stevens & Akah, 2018). In order to determine if S.B. 51 was effective, patients who were prescribed or ordered non-opioid medications and/or therapies would have to be followed in order to conclude if these options were effective in treating their pain. With the success of these options, a decrease in opioid users should also be evident.

Identification of Elected Official

State Senator Tina Maharath (D-Columbus) represents the 3rd Senate District and is serving her first term in the Ohio Senate after being elected to the General Assembly in November 2018.  She was chosen as the elected official to interview because she is the main sponsor of Senate Bill 51 (S.B. 51, 2019).


The current opioid crisis occurring in our country is one of the greatest public health crises of our time.  The State of Ohio has been hit especially hard and was ranked second highest in the rate of opioid related overdose deaths in the United States in 2017 (National Institute on Drug Abuse, 2019). The problem started in the 1990s when the pain was added as the fifth vital sign in order to improve the treatment of pain which led to the overprescribing of opioids by physicians (Anson, 2016).

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It was soon realized that patients were becoming addicted to these medications even though the drug companies said they were “safe.”  When this reality come to light changes were made limiting the prescribing of opioids which decreased access for patients. Unfortunately, that led many patients to switch from legal to illicit drugs fueling our opioid crisis with devastating effects.

Non-Opioid Directives In addition to addiction treatment, healthcare providers need to rethink how they treat pain. The old habit of prescribing opioid therapy as the first line of treatment for pain is no longer the best practice.  Another important step is to be proactive by utilizing prescription drug monitoring programs in order to identify suspicious patterns of opioid use. We also need insurance companies to start covering effective, evidence-based non-opioid pain remedies.

The underinsured could benefit from an expansion of coverage through the Affordable Care Act which would help to increase access to preventive care and possibly eliminate the need for painkillers.  Nurses have the knowledge and the power to advocate for their patients and can lobby for change.  It is our responsibility to do so in order to improve patient outcomes and promote healthy communities.  S.B. 51 can certainly promote change in the right direction.  By promoting the use of non-opioid treatment for pain, we can expect to see improved patient outcomes and less devastation caused by opioid use and abuse.


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Non-Opioid Directives And Coverage Of Non-Opioid Therapy

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