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.