s the abuse of prescription painkillers stubbornly persists across the country, nearly half of the states have attempted to cut off the supply at its source in the past year, by making it harder for doctors to prescribe the addictive pills to Medicaid patients.

States such as New York, Rhode Island, and Maine adopted new limits on the number of pills that doctors can prescribe, and West Virginia will, starting next year, require prior authorization from the state’s Medicaid program for opioid painkiller prescriptions. 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. Research indicates that 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 a fatal overdose.


The rules can take the form of seemingly straightforward controls such as limiting prescriptions to a one-month supply and requiring patients to pick up their doctors’ written re-fill order in person. For some physicians and patient advocacy groups, though, they are problematic.

“This is really going to limit patient access,” said Dr. 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.”

Many states acted after the federal Centers for Medicare and Medicaid Services released a list of “best practices” last January, which encouraged state Medicaid programs to adopt more stringent requirements for opioids. Some states had already done so, but the CMS advisory accelerated the trend.

A total of 46 Medicaid programs have put in place prescription caps, 45 require prior authorization, 42 need proof that patients meet medical criteria to receive opioids, and 32 allow the drugs only after patients have exhausted other options, which is called step therapy.

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 Responsible for Opioid Prescribing, an advocacy group. Both overdose deaths involving prescription opioids and US sales of the drugs have roughly quadrupled since 1999, with more than 14,000 deaths reported in 2014, according to the Centers for Disease Control and Prevention. Others addicted to pain pills die after switching to opioids such as heroin and fentanyl, which often sell for less on the street and pack more of a punch.

But some physicians argue that 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 who already are suffering intense pain, making travel a hardship, have to visit the doctor more often for medicine absorbing time and extra money for gas or public transportation.

Worried about creating such barriers, some state Medicaid officials are trying to strike a balance between limiting abuse and allowing reasonable access to medications.

Louisiana’s Medicaid program, for instance, has capped the number of pills a doctor can prescribe, so a prescription can’t span longer than 30 days, and it 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 prior authorization for opioid prescriptions.

But years of budget cuts mean there’s not enough money to properly cover a robust array of alternatives to opioids. For example, beneficiaries are limited to one visit with a pain specialist.

“It’s not enough,” said SreyRam Kuy, Louisiana’s Medicaid medical director.

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

Massachusetts’s Medicaid program 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 options such as acupuncture and tai chi or yoga classes, 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 insurance coverage generally has worked to drive down prescriptions of other particular drugs. But “these are blunt instruments,” Diaz said. “We do have to be thoughtful.”

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 opioids. 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.”

This story was published in partnership with Kaiser Health News.

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  • There is no doubt in my mind what so ever that these arrogantly judgmental fools do not know what its like to be forced to work physical labor with conditions that causes moderate to severe chronic pain. Pain gets to your head after a while even if its not off the charts. The arrogance and audacity of these judgmental incompetent weasels sickens me….absolutely Deplorable.
    Its inhumane to do this. I feel its all about money…they dont care about addiction, nor do they care about other people’s suffering. Welcome to the 21st century of Egotistical bias conformity.

  • 95% of the pain patients in the US, who these meds are vital, as Nothing has been developed that holds a close second, pay for the well published 5% of abusers/diverters. No evidenced based research applies here. Research who wrote those guide lines adopted by the cdc. It will tell you what the press doesn’t

  • I cringe when I think of the ides that my mom who has severe back problems may have to live her daily life in pain as she does so now daily? With many of you that aren’t older and have no pain yet, it’s easy for us (the ones without pain) to say no one needs medications for their daily lives? People wonder how come there are those turning to heroin and things of that sort? I for one am not nor will I ever be (I pray) on pain medicine but I see my mom suffer daily in pain and there are many many things she just cannot do? Yoga would be a complete joke she can’t even get up and down on thes floor? I’ve seen my mom cry true tears in pain and sh’s a strong woman? I don’t condone those that definitely don’t need pain nedicines that they should have the right to even be perscribed at all? But people in the shape shch as my mom? Shame on those of you that want to totally do away with what those of them that do need them making it extremely hard on them? Yal are the knes to blame for many heroin over doses yourselves!!

    • Most of the people being, I should say needing, a pain drs are literally being shunned and treated in the most inhumane way right here in the U.S. Countless of those people can’t even find a Dr willing to treat chronic pain. Pain Patients are already treated like criminals, made to undergo a stringent protocol to begin with. They first have find the needle in the hay stack called a Pain Dr to treat them, which is next to impossible now. Most say, epidural then cutting you open, no marcotics- don’t even ask. Those who have morals and ethics evaluate each patient with factual information, previous therapies, scans, epidurals, PT, etc in order to see this is an ongoing issue. Then the patient must submit to drug testing at every appt and randomly (meaning Dr office calls and you drop what you are doing and get in there IMMEDIATELY to give a urine sample, swab, whatever they request.) Never mind if you have a job you need to be at or kids to care for. Then there is the national database to show every medical field what you have been precribed, when and by what Dr to completely cut out any chance of Dr shopping. A contract is signed saying you agree to submit to drug tests, use the same pharmacy (who refuses to ever have your medication in stock or agree to order it) and you’ll not see any other Dr for pain meds or you are immediately abolished by the clinic.
      Drs, nurses, minute clinics, insurance, and pharmacies have access to ALL this database information with a simple key stroke. Drs also only prescribe long term when everything else has been fully exhausted- PT, traction, over the counter meds, ice and heat, acupuncture, yoga, a head Dr sometimes even. That’s including surgery which often makes the pain that much worse, causing new problems while not correcting the original problem.
      Pain Drs have knowledge and expertise in pain. They know more about it than majority of physicians and they know what works and what doesn’t and what can be tried and they know their patients on a very personal basis. However, excellent pain management drs are now being threatened to have their license taken if they follow their oath to care for their patients. Instead they must make a choice, career or principle. That’s awful. Most Drs who went to many many years of schooling now only will do epidural or refer pt to an ortho Dr for surgery afraid of the governments big brother approach and their license being stripped from them. These Pain Management Drs are now eessentially reduced to a minute clinic P.A or Dr who treat minor, non serious, acute things- and again they specialize in PAIN MANAGEMENT.) Those pts who’ve been down that road and done every possible thing known to man. Those who’ve spent an absorbent cost to get well are literally treated like society’s trash now. They are refused care and treated as criminals for simply wanting a tolerable amount of pain, so they can still have a meaningful life and not become a burden on society. So, how does that make sense that the government is inhumane to them by making law abiding, good people suffer dibilitaing pain each and every day while continuing to take more and more of the medication, good drs and quality of life away from them? They are knowingly forcing them to seek other means to be well. People who would otherwise never be on the streets looking for narcotics to ease their pain. People are commuting suicide because they can’t physically stand the pain they live in each and every day. Instead of acknowledging that, they are limping them in with the addicts who OD on a cocktail of shit (crushing/scraping, snorting pills and ingesting any chemical they can find to get them high as a damn kite and comatose. Pain patients are not those people. Pain patients are your grandma, aunt, cousins, sister, child. This war on opiods is a common sense outcome- more street drugs, more actual criminals in your neighborhoods filling supply and demand. More crime and more death than anything we’ve ever seen. And those on long term pain meds are 1% when it become to becoming addicts if you actually do your research. To make that look astronomically higher, the CDC & DEA, even many sad so called Drs are putting known addicts into the equation to beef up the number to make the inhumane treatment of humans here in the U.S look justified. Those who happen to do a cocktail of drugs (pill form and street drugs with the intent of abusing them with the sole purpose of getting high out their freaking minds- who will use any means necessary, including pills they find, syrups, paint cans, alcohol, chemicals meant for peeling paint off cars in order to achieve their end goal of being high.) These people are NOT the typical and every day chronic pain patient. They are addicts with addict behavior, but 1% just doesn’t sound scary enough, so they must lump everyone together to demonize even the innocent and most vulnerable people who are just needing a Dr to help them live a happy, full life.. Not pain free. We know we’ll never achieve that, but so it’s bearable. How in the heck does our society demonize our loved ones who are in pain and need help like this? Meanwhile everyone speaks on this topic as it makes any kind of sense or is humane in any way to do to someone when we have the best medical science available to us. People stay naive, and calloused until this is a person in your own life you have to see suffer in great pain and whom are refused help by the best drs, best medical care and tossed out door after door. It’s inhumane. It is not what the oath Drs take is and people need to start speaking up for our more vulnerable citizens. This is shameful and frankly disturbing, disgusting and scary. If Trump, the DEA, CDC, Drs and those groups care so much for drug addicts, why are there not nearly enough rehab facilities afforded to them? Because they don’t care and they have no interest in actually helping addicts either.

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