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Tighter Prescribing Rules: An Anti-Abuse Strategy That Could Hurt Patients In Pain

Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

As rates of prescription painkiller abuse remain stubbornly high, a number of states are attempting to cut off the supply at its source by making it harder for doctors to prescribe the addictive pills to Medicaid patients.

Recommendations on how to make these restrictions and requirements were detailed in a “best practices” guide from the federal Centers for Medicare and Medicaid Services.

But the move is prompting worry from some physicians who say it could have the unintended consequence of keeping appropriate medical treatment from people with chronic pain.

The CMS protocols, released last January, encourage but do not demand that state Medicaid programs adopt more stringent coverage requirements for opioids, such as requiring physicians to get prior authorization before writing a prescription or stipulating that patients try other treatment options first, which is sometimes called “step therapy.” Patients may also have to provide proof that they meet certain medical criteria in order for their pain pills to be covered.

Some states’ efforts to curtail prescribing predated CMS’ bulletin. But the advisory added new fuel to the trend. States such as New York, Rhode Island and Maine adopted new prescription size limits this year, and West Virginia will require prior authorization starting next year. In the 2016 fiscal year, 22 states either adopted or toughened their prescription size limits, and 18 did so with prior authorization.

The goal is to make physicians think twice before prescribing the highly addictive medicines — a change many say is necessary, especially within the state-federal health insurance program for low-income people. After all, research indicates Medicaid beneficiaries are prescribed opioids at twice the rate of the rest of the population, and are at three to six times greater risk of an overdose.

They can take the form of seemingly straightforward controls such as limiting prescriptions to a one-month supply and requiring patients to pick up the doctors’ written refill order in person. For some, though, they are problematic.

“This is really going to limit patient access,” said John Meigs, president of the American Academy of Family Physicians, and a practicing doctor in Centreville, Ala. “There are patients with legitimate pain, who have legitimate need.”

So far, state policies increasingly echo the CMS suggestions. Forty-six Medicaid programs have put in place prescription caps, 45 require prior authorization, 42 need proof of meeting clinical guidelines and 32 allow the drugs only after patients have exhausted other options.

Some commercial plans are also using these kinds of strategies, though experts said it’s unclear how far that trend will spread.

“This is an indication that policymakers are finally recognizing that overprescribing of opioids is fueling the epidemic,” said Dr. Andrew Kolodny, a Brandeis University senior scientist and the executive director of Physicians for Responsible Opioid Prescribing, an advocacy group.

But others note this perspective overlooks the separate, underlying challenge of treating a chronic condition. “Just because it is now harder to prescribe patients opioid medicines, it does not mean we have fewer patients who have pain,” said Dr. Eric Weil, the associate chief for clinical affairs in internal general medicine at Massachusetts General Hospital in Boston.

Such restrictions can become a difficulty, especially since Medicaid beneficiaries already are dealing with limited means.

For instance, a smaller prescription dose means patients — whose chronic pain makes making travel a hardship — have to visit the doctor more often for medicine. Not only is that difficult, it can absorb time and extra transportation money.

That kind of experience is leading some state Medicaid officials to seek a balance between limiting abuse and allowing reasonable access to medications.

Louisiana’s Medicaid program, for instance, already has capped the number of pills a doctor can prescribe, so a prescription can’t span longer than 30 days, and requires proof that clinical guidelines have been followed before opioid painkillers are used. State officials are eyeing additional changes, such as lower prescription caps and potentially requiring prior authorization for opioid prescriptions.

But there can be a tension between these limits and coverage of other pain management options. For example, beneficiaries are limited to one visit with a pain specialist. They also can receive prescriptions for some less powerful and usually less effective pain medications.

“It’s not enough,” said Dr. SreyRam Kuy, Louisiana’s Medicaid medical director. And years of budget cuts to the program mean it’s difficult to pony up the funds to properly cover a robust array of care options.

“We need much more to address this,” she said. “If you just cut off the pills, it’s not addressing the bigger picture.”

Massachusetts also has in place some of the prescribing controls. But it, too, is “pretty haphazard” when it comes to making alternatives available, Weil said.

That’s a real concern, said Dr. Steve Diaz, an emergency physician in Maine, who is consulting with that state’s Medicaid program as it develops its regulations. The patients being squeezed often don’t have extra money to pay out of pocket for things such as acupuncture, tai chi or yoga class, all of which can sometimes be used to help manage pain, he noted.

That said, given the spread of opioid abuse, using insurance rules to curtail prescribing makes sense, he said. And while evidence is limited, restricting coverage has worked to drive down prescriptions of other particular drugs.

But “these are blunt instruments,” he said. “We do have to be thoughtful.”

That’s why some are trying other tacks. At Massachusetts General, Weil said, the hospital’s teaching doctors about other approaches, but also providing regular feedback and tracking how often physicians prescribe opioids. The idea, he said, is to go beyond education, which “tends to last a good 90 days, and then people forget.” By building in feedback loops and reminders the hospital hopes to drive a deeper culture shift and have more meaningful impact.

Meanwhile, if Medicaid plans try to curb physician painkiller prescribing, they need to be nuanced, Kuy said. For instance, states must account for people such as cancer patients, who may legitimately need heavy-duty painkillers. Carving out the right kinds of exceptions, Diaz said, will be a major challenge.

And, experts noted, it’s still unclear if these strategies can make a difference.

“Will these policies have the intended effects? There’s very limited evidence [they will],” said Dr. Jonathan Chen, an instructor at Stanford University School of Medicine, who has researched opioid abuse. “On the other hand, the problem has grown to the point where we have to do something.”