A Harbinger of Things to Come?

Blue Cross Blue Shield of Massachusetts recently announced that, after consulting with “an external advisory group of pain management experts, addiction experts, and primary care providers and pharmacists” to develop “a comprehensive program to promote evidence-based, safe, high-quality opioid prescribing,” beginning July 1 the insurer will enact policies that will restrict physicians’ ability to prescribe short-acting opioids for some patients (http://bit.ly/M4HYr8). According to a news release from Blue Cross Blue Shield of Massachusetts (http://bit.ly/KRCjB1), these measures were designed to “limit possible prescription narcotic misuse and dependence among its members.” Under the new policies, physicians will have to create a treatment plan that includes “a clear diagnosis, explicit goals and exploration of other treatment options for pain,” conduct a formal assessment of addiction risk and obtain informed consent from the patient that he or she understands the risks involved in taking prescription pain medications, create a written pain contract that covers “issues of prescription management, diversion, and the use of other substances while taking pain medication,” and establish with the patient that all of his or her opioid prescriptions will be written by only one provider and will be filled by only one pharmacy.

The insurer stated that internal reviews revealed that “more than 30,000 of its members have received prescriptions for short-acting pain killers lasting longer than 30 days,” a practice that “many experts believe increases the chances of drug misuse, dependency, and diversion.” Therefore, under the new policy physicians will be able to prescribe only a 15-day supply of short-acting opioids, with one 15-day refill. When the refill runs out, the prescribing physicians must receive authorization from the insurer before additional prescription opioids will be approved. According to an article in The Intractable Pain Journal (http://bit.ly/MDQvQe), “whether patients receive care beyond the 30-day period will be in the hands of an advisory panel. Doctors must officially request the ability to extend pain treatment via the BCBS panel,” which could take up to 72 hours to decide whether to approve the request. Once a determination is made, “the patient and his/her provider will be notified of the decision in writing.”

Other provisions in the new policies include restrictions limiting opioid prescriptions containing acetaminophen to four grams of acetaminophen per day (this applies to new and existing prescriptions), requirements for prior authorization for new prescriptions for more than 30 days worth of longacting opioids, and requirements for prior authorization of buprenorphine. Kaiser Health News has reported that Blue Cross Blue Shield of Massachusetts has announced that “patients with such serious or chronic conditions as cancer or those who are terminally ill will be permitted to continue to receive opioid painkillers” under the old rules (http://bit.ly/Ld1DGp).

Is this top-down approach to limiting access to prescription opioid medications the first glimpse of how private sector payers are going to respond to the increase in opioid abuse, diversion, and overdose deaths? Following in the wake of the recent announcement by the Centers for Medicare and Medicaid Services that it will soon tighten its review practices and implement safety protocols that will allow Medicare plans to decide what constitutes “medically necessary” pain management and empower them to intercede in the clinical decision making process and deny patients access to the pain medications prescribed by their physicians (see the March issue of Pain Management for more on this), this appears to be a worrisome continuation of the recent trend toward loss of physician autonomy in pain medicine. With the hype and attention focused on the potential risks associated with the use of opioid therapy for treating chronic pain reaching a fever pitch, we can expect to see more state, federal, and private sector attempts to second-guess, review, and otherwise police doctors’ pain management prescribing decisions. Unless the pain management community takes stronger measures to push back against these encroachments it will witness the steady erosion of prescribing authority, further intrusions on the doctor-patient relationship, and loss of access to needed medications for patients suffering with chronic pain.