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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.

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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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  • I have spent 25 years going to physical therapy, accupuncture, massage therapy, injections, nerve blocks, ect ect. You name it, I’ve tried it. I’ve ever been on muscle relaxers and pain meds, ect. Now the only thing that’s helped me to date is opiods. I’m seeing a professional pain doctor who specializes in this area and only prescribes me thirty 15mg oxycodone per month. Now Medicaid is attempting the pull the plug on that, even though the doctor put in for a prior auth and explained to them that I’ve exhausted all other avenues. I take the medication responsibly under her supervision and I don’t abuse it. She even drug tests me every month. But Medicaid is still pulling the rug out from under me, claiming that she’s adding to the national epidemic. No she’s not…..She’s following the rules (national and state), and she’s handling everything properly. Yet they’re going after the doctors now more than the patients. It’s out of control. Now the good people are suffering. I have cellulitis, 6 bulging discs, 4 herniated discs, edema, 1 crushed disc, and a partridge in a pair tree. I’m just saying, the system is now designed to go after the patients who actual qualify for this medication in a justified manner, and it’s going to get worse. What about people dying of cancer? I heard a senator complain that he’s sorry he recently signed a bill making it far more difficult to get this kind of medication and now his wife is suffering in severe pain from terminal cancer, and he’s having a very hard time getting her this kind of medication. So now he regrets it. Well no kidding…….surprise surprise……So for any senators reading this, “stop attacking the doctors and the people who need this stuff……people are suffering greatly…….”

  • I am a very young woman aged 39 on methadone for stage for terminal cancer in my breast lungs and bones. I went to methadone from Fenton all because I did not want to be extremely medicated with high dose of pain medication. Now, hearing this opiate crisis has me terrified because if I go through methadone withdrawal I won’t even be able to get out of bed and care for my seven-year-old child let alone function. All this will do is help me search for a Dr. Kevorkian so to speak. I completely understand cracking down on opiates to those who are Dr. shopping and do not legitimately need them but a terminally cancer real patient that is not even on a very addictive pain medication like methadone that doesn’t even give euphoria after I believe a week or two and I’ve been on it for six years now to where it’s just like taking an Advil is beyond ridiculous.

    • P.S. for those who are not familiar with methadone, it has an extremely long half life and is a brutal withdrawl. I have been through it before off 130 mg and I am only on 120 now and I would never put my worst enemy to death. I would rather from what I hear kick heroin 100 times over then one methadone withdrawal. I would be depressed for months if not years and physically ill and week beyond comprehension to where I won’t even want to live in that’s the honest to God truth so if you’re unfamiliar With methadone, please do your research because my mother-in-law does not understand even though she knows that I have terminal cancer in three places in my body.

    • I understand what you’re saying. Looking for an internal medicine doctor or a pain management doctor. If you have stage 4 cancer, they’re likely to help you. If you have stage 4, I wouldn’t worry about being on medications too strong. That’s the one thing that’s going to help you. And methadone is a good drug for pain, and it usually isn’t too strong if taken properly. It allows you to function. Try something called Opana. It’s like Oxycodone. Basically the same thing. But time release dosing.

  • I think it’s very unfair to take away these pain medicine when people who really need them is suffering I have severe Osteoporosis in my back and hip and osteoarthritis in both knees,,,I’m on medicaid and need my medicine!

  • If the last president had put the FDA to work, better pain meds could be used. They took away Davocets? Older people used them and now were forced to take stronger pain meds. My 90 yr old mom doesnt like norco etc. Its to strong. I have medal in my arm, fibromyalgia and stenosis of my spine and more. I ache very much 24/7. I am on low dose of pain meds. I wont be able to continue helping my daughter live alone she is terminal and i have to do alot daily to keep her alive. If they cut me, i will do best i can but i feel i will deteriorate. I truly suffer in areas that will only get worse. Onama let soooo many drs write back ally scripts in Fla for his 2 terms! He looked the other way as did FDA. Now were in trouble. Cant have millions going thru withdraw. Hope they look at each individual on pain meds. Help those still in need. Amen i am age 56

  • I’m a 42 yr old woman on Medicaid with bad fake hips that badly need to be redone(among other problems that cause severe pain on a regular basis), but haven’t been able to find a surgeon to fix them yet, just another Medicaid hit. So pain management was my only way to have any form of day to day normal life without being in tears&my heart being overstressed from the excruciating pain. Thanks to the very wrong way the insurance companies, politicians&Dr’s are handling this problem I’m not only back to being bedridden since my already way to low dose of pain medication has been lowered to nearly nothing, but now I also have a heart condition(requiring medication to try to prevent heart attack) due to the tremendous amount of stress dealing with my pain has put on it! And it continues to be more stressed everyday now, so not only has being punished for those who were irresponsible with their meds put me back in bed 95% of the time but also may cause my death from not properly being medicated for my pain via a heart attack. My heart Dr has tried to talk sense into my pain Dr but as he said “If she O.D.s, I get sued&lose my licence. Then how will I make a living?”. My Dr told him “So write up a waver for all patient’s on opiates to sign stating if they O.D. by misusing the meds, you aren’t liable. Then before even giving opiates to a patient make it clear what can happen if they misuse the meds, explain how narcan works and send them home with narcan nasal spray. Because if a patient has a heart attack and dies due to the stress caused by dealing with pain you will most definately be sued by their family for that! What’s being done to patients in this situation is irresponsible and against the oath we took yet people aren’t going to see it until it’s to late”. Which I told him initially&even though I tried telling my pain Dr, my heart Dr hoped he’d get through…. not! The way this epidemic is being dealt with is not going to work people! As less can be given in script form, the more people are going to turn to the streets for pain relief or a fix. Drugs like heroin aren’t regulated which means there are going to be more deaths from O.D.s from those drugs compared to prescription O.D.s ever have. Then you’re going to have people like me having heart attacks and being killed from lack of proper pain relief. Plus those who end up committing suicide because they either can’t live with The excruciating pain day to day any longer or The fact that they have no life because it hurts to much to move around. The death tole is going to rise very fast and sadly it seems that’s what it’s going to take to fix this three correct way. My pain is so bad most days I wonder if death would be better at times. Since pain management has little to no chance of happening I keep holding on to the possibility of someone finding a surgeon that could at least redo my hips as to alleviate some of the pain and allow me to get out of bed and be able to do things again…. to be able to not just be alive but yup live again! But i have instructed my family if the impending heart attack does take my life they are to sue each Dr that refused to medicate me, especially those my heart Dr tried to talk to as well then start making as much noise as possible where politician’s, insurance companies and other Dr’s neglecting their patients as mine did to me until things change in the right direction! Including not putting all chronic pain patients in the same category as a “junkie” or street addict….. THERE IS A HUGE DIFFERENCE PEOPLE!

  • 4 cervical/lumbar rebuilds. Pain unbearable. Zero quality of life for 6 yrs. Wanted to die. Finally went to pain clinic. Did every procedure, therapy available. Pain still unbearable. Pain clinic finally got the right recipe of meds. Followed pain contract always, compliant. Now they are cutting my meds back to the point i am taking motrin, Tylenol, aleve with no relief. Activity less, pain more. Dr looked at me with a smirk, said too bad. This is why i put off going on narcs. I never thought after finally getting my life back to where I have good quality. Too bad. So heroin is my new pain med? How is this helping to curb opioid abuse? I never abused my rx but now I am being made to suffer.

  • But those like me who need these medications are being left out of the story! I’m a 42yr old woman with 2 failing prosthetic hips, can’t find a surgeon to fix them, have a heart condition due to being forced to dealing with the debilitating pain&when I’m off meds completely my heart Dr is certain the stress from the pain WILL most definately cause me to have a heart attack at this point. Its not fair that people that need the meds are being punished for those who misused theirs. So I deserve to have no life&have a heart attack in the very near future because someone else was irresponsible…. i don’t think so! I know alot of you look at chronic pain patients as junkies but why is it ok to get pain meds of you have cancer but mine isn’t worth helping? Plus, now the DEA is checking up on patients being given opiates. So everyone else must follow the hepa laws but a bunch of gov officials that never went to medical school have the right to see my medical files&decide what’s good for my health? I don’t recall signing a release for that! Please stop ignoring&punishing people that need these meds because others misused them. It’s a problem that people od but dying of a heart attack due to not being on proper meds is ok? Not right! Your gonna see more deaths once more people are made to deal with their pain in the form of suicides&heart attacks. Hope the country is ready for that!

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