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Will Tighter Prescribing Rules Hurt Patients in Pain?

States adopt strategies to curb painkiller abuse

As rates of prescription painkiller abuse remain high, several states are attempting to cut off the supply at its source by making it harder for physicians to prescribe potentially addictive opioids to Medicaid patients. Recommendations on how to impose these restrictions were detailed in a “best practices” guide from the Centers for Medicare and Medicaid Services (CMS).

The CMS protocols, released in January, encourage but do not demand that state Medicaid programs adopt more-stringent coverage requirements for opioids, such as requiring physicians to obtain prior authorization before writing a prescription or stipulating that patients try other treatment options first (step therapy). In addition, patients may have to provide proof that they meet certain medical criteria in order for their pain pills to be covered.

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, according to a report from Kaiser Health News.

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 medications. 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 an overdose, according to the Kaiser report.

“This is an indication that policy-makers are finally recognizing that overprescribing of opioids is fueling the epidemic,” said Dr. Andrew Kolodny, a senior scientist at Brandeis University.

But others note 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, of the Massachusetts General Hospital in Boston.

Moreover, the tighter prescribing rules can become a difficulty, especially since Medicaid beneficiaries already are dealing with limited financial means. 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, the Kaiser article notes.

Some state Medicaid officials have sought a balance between limiting abuse and allowing reasonable access to medications. Louisiana’s Medicaid program, for example, 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 can be used. State officials are eyeing additional changes, such as lower prescription caps and potentially requiring prior authorization for opioid prescriptions.

If Medicaid plans try to curb physician painkiller prescribing, these efforts need to be “nuanced,” said Dr. Srey Ram Kuy, Louisiana’s Medicaid medical director. For example, states must account for people, such as cancer patients, who may legitimately need potent painkillers.

But it’s still unclear whether these strategies will make a difference in the long run, according to the Kaiser article.

“Will these policies have the intended effects? There’s very limited evidence [that 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.”

Source: Kaiser Health News; November 30, 2016.

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