Insurers Promise More Cuts in Rx Opioids

By Pat Anson, Editor

Less than two weeks before its final report is due, President Trump’s opioid commission held its fourth and final public meeting Friday – hearing testimony from top government officials and insurance industry executives about the nation’s worsening overdose crisis.

“Insurance companies are going to be a very, very important part of whether we will be able to stem the tide here or whether we’re not,” said commission chairman Gov. Chris Christie of New Jersey.

It was clear from their testimony that many insurers are planning to tighten access to prescription opioids even more than they already have.

Aetna’s chief medical officer told the commission the insurance giant was planning to reduce “inappropriate opioid prescribing” to its members by 50 percent within the next five years.  He did not explain what would be considered inappropriate.

Aetna has already sent warning letters to hundreds of physicians and dentists identified as “super-prescribers,” urging them to reduce the number of opioid prescriptions they write.

“We’re now re-running our analysis and planning more aggressive interventions for those providers who haven’t improved their opioid prescribing habits over the past several months,” said Harold Paz, MD.  

The chief medical officer of Cigna said his company was close to achieving a 25 percent reduction in coverage of opioid prescriptions, a priority it set last year.

“That’s only the first of our goals,” said Alan Muney, MD.

Insurer Harvard Pilgrim said its coverage of opioid prescriptions has declined by over 20 percent since 2014.

“That’s not enough.  This feels like a balloon where you tap on one end and it comes out somewhere else. So it doesn’t mean we’re even close to solving this,” said Michael Sherman, MD, chief medical officer of Harvard Pilgrim.

Insurers clearly have the ear of the federal government when it comes to opioids. As PNN has reported, an obscure federal advisory group composed of insurers, law enforcement, and federal and state regulators has discussed eliminating opioid prescriptions for acute pain, as well as paying doctors not to prescribe opioids.

The Healthcare Fraud Prevention Partnership also wants access to the “personally identifiable and protected health information” of 57 million Medicare beneficiaries to see if they are abusing opioids.

Reducing Opioids a ‘Win-Win’

Labor Secretary Alexander Acosta said reducing opioid prescriptions was important to get unemployed Americans back into the workforce. He cited a recent study that found that about a third of unemployed men aged 25 to 54 were using prescription painkillers.   

“Reducing the amount of opioids is a win-win across the board. It’s a win for the individual who doesn’t want to get hooked,” Acosta said. “It’s a win for the insurance companies who don’t want to be paying for medicines that people don’t need. And it’s a win for the American workforce, because if we can get people back to work and paying taxes and participating fully, that’s a win for them and it’s a win for the country.”

Acosta cited no studies that might indicate how many Americans currently taking opioids would become unemployed or disabled if their pain medication was reduced or taken away. 

No pain patients, patient advocates or experts in pain management were asked to appear before the commission. No one from the pain community has testified during any of the commission’s public meetings, although thousands have submitted written comments.

An interim report released by the opioid commission in July focused on expanding access to addiction treatment and developing new ways of treating pain without opioids. Since then, the commission has increasingly focused on limiting opioid prescriptions. The final report from the commission is expected November 1.

The interim report also strongly urged President Trump to declare a national emergency to speed up efforts to combat the overdose crisis, something he has yet to do.  “We’re going to be doing it in the next week,” Trump told reporters on Monday.  However, there appears to be little consensus in the administration about what actions to take after an emergency is declared or how to pay for them.

"Everyone wants opioids to be a priority, but there's a lot of resistance to calling it an emergency," a senior administration official told Politico.

Pain Patients Say Insurers Interfering with Treatment

By Pat Anson, Editor

It’s no secret that health insurance companies have been raising deductibles and co-pays, and generally making it harder for chronic pain patients to get treatment – whether it’s opioid pain medication or alternative therapy like massage or acupuncture.

But recent actions by some insurers have healthcare providers and patients saying the insurance industry has gone too far in its effort to reduce opioid abuse and is interfering with the doctor-patient relationship.

“My own insurance company just acted as a physician to remove the meds that I need by blackmailing a kind-hearted pain doctor,” says Jennifer Nelson, who has suffered from Reflex Sympathetic Dystrophy (RSD) in her left foot for nearly two decades.

The “blackmail” Nelson refers to is a form letter her pain management doctor received from Blue Cross/Blue Shield of Michigan warning that opioids, benzodiazepines and a muscle relaxant named Soma (carisoprodol) should not be prescribed together. Benzodiazepines such as Valium act as sedatives and are known to increase the risk of overdose when taken with opioids.

But Nelson says she’s used them safely for years to reduce pain, muscle spasms and to help her sleep.   

“Their threat is to pull their coverage from his office if even one patient tests positive for both opioids and benzodiazepines. So now my health insurance has become Big Brother?” said Nelson in an email to Pain News Network. She also included a copy of the form letter sent to her physician.

JENNIFER NELSON

“There is no legitimate medical indication for this combination of controlled substances,” the letter from Blue Cross/Blue Shield (BCBS) says. “If the diagnosis is opioid abuse or dependence, the continued use of sedatives is contradicted and the continued use of opioid analgesics is against DEA regulations. If the diagnosis is legitimately chronic pain, benzodiazepines are still contradicted as they lead to a downward spiral of pain control and function.”   

The only downward spiral Nelson feels is from having her Valium tapered.

“The muscle spasms came back with a vengeance,” she says. “The second night I woke up and I thought someone was pulling my leg off.”

 “I am very concerned that an insurance company states there is ‘no legitimate medical indication’ for the combination of opioids, benzo's and Soma,” says Lynn Webster, MD, past president of the American Academy of Pain Medicine.

“No (insurance) payer nor the DEA should be making this type of dogmatic statement.  Such a statement will be used by the DEA to prosecute any provider who prescribes this combination.  It is inappropriate for either a payer or the DEA to determine what a legitimate medical indication is for any single or combination of drugs prescribed.”  

Webster agrees that combining benzodiazepines with opioids is risky, but says Blue Cross/Blue Shield went too far.

“What is most lacking from the letter is an alternative.  BCBS has a responsibility to offer alternatives to the providers on how to treat anxiety in people who also have pain and or opioid addiction and anxiety,” Webster wrote in an email to PNN.

“I agree the combination of opioids and benzos and other CNS depressants should be avoided, but if the payer wants to practice medicine then they should make it clear that they will pay for cognitive therapy and other alternatives as long as it is needed or pay for other medications that are not as risky as benzos. It is unacceptable to just abandon people with pain, anxiety and/or addiction.”

Aetna “Super Prescribers” Warned  

The insurance company Aetna sent a similar letter to nearly 1,000 physicians in August, warning them about their opioid prescribing habits. The doctors were identified as “super prescribers” by Aetna after a review of insurance claims.

"You have been identified as falling within the top 1 percent of opioid prescribers within your specialty," the letter states.

Aetna’s chief medical officer told The Washington Post the letter was not meant as a threat, but merely a note of caution.

"We're asking you to look at your practice...and identify if the way you're prescribing narcotics is best practice," said Harold Paz, MD. "And if it's not, here's an opportunity to improve."

Kaiser Permanente – an HMO -- is also urging doctors in its network to reduce opioid dosages to those recommended by the Centers for Disease Control and Prevention. The CDC’s guidelines say prescribers “should avoid increasing dosage” over 90 mg of morphine equivalent units a day.

“That dose does nothing for me,” says Scott Michaels, who at age 55 is permanently disabled by severe back pain, arthritis and other chronic illnesses.

Michaels has a genetic condition that causes him to metabolize opioids quickly. For seven years, he’s been taking a daily opioid dose of 330 mg of morphine equivalent units – nearly four times what CDC and Kaiser Permanente recommend as a ceiling.

“I have a terrible metabolism so the medication goes right through me, hence the high dose. As of last month, Kaiser is reducing me 10% a month until I’m at 90 mg. I have no choice they said. The pain is already coming back and they don’t care,” said Michaels, who asked that we not use his real name.

“Kaiser is an insurance company and provider. To me that is a conflict of interest. I just don’t know what to do. It can’t be legal to withhold medication that has proven for me to work.”

Jennifer Nelson was also on a high dose of opioids that is now being reduced by her doctor to reach the levels recommended by the CDC. She says her health has deteriorated significantly and she’s worried about become bedridden.

“I lived a very high functioning life. My biggest fear is my seven year old not having a Mom to walk him to the bus stop," Nelson says. “Nineteen years and I've never overdosed or used my meds incorrectly. I submit to random urine tests and pill counts, and educated myself on my meds. So what do we do? Can insurance companies legally threaten doctors like that? And why are they quoting CDC guidelines when doing so? I'm infuriated. Exhausted, unable to sleep, gritting my teeth in pain, but infuriated.”

Insurers say their efforts to wean patients off high doses of opioids are producing results. Blue Cross/Blue Shield of California says its Narcotic Safety Initiative has resulted in an 11% reduction in members using the very highest doses and “prevented” 25% of all new opioid users from using the drugs for more than 90 days.  

Will these new policies also reduce the number of people dying from opioid overdoses?

Blue Cross/Blue Shield of Massachusetts – one of the first insurers to adopt tougher prescribing policies – says it has reduced the dispensing of opioids to its members by 15 percent since 2012.    But the new policies failed to slow the growing number of opioid overdose deaths in Massachusetts, which more than doubled.