Opioid laws hit physicians, patients in unintended ways

on May21
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2018-07-31 10:00:00

Beginning June 1, Public Act 248 of 2017 requires physicians who want to issue a prescription for more than three days to first check with the Michigan Automated Prescription System, the state’s online database that houses information on prescriptions for opioid and other controlled substances. The act excludes prescriptions written for a patient in a hospital or ambulatory surgery center.

Fred Van Alstine, M.D., a family physician in Traverse City who specializes in palliative care and is a hospice medical director, said there also should be exceptions in opioid laws for hospice patients and those in palliative care who are dying.

“This was a solution looking for a problem. … It is an administrative burden because our patients are end of life and they need” opioids to control pain, Van Alstine said.

James Forshee, M.D., Priority Health’s chief medical officer, said his company’s prior-authorization rules on opioids exempt patients in palliative care, hospice or in cancer treatment.

“The whole effort of the law is to reduce opioid use, prevent addiction, misuse and abuse,” Forshee said. “That is not an issue with palliative care and hospice treatment. Pain control is the primary purpose.”

Bush said the opioid laws’ blanket restrictions illustrates the quandary physicians sometimes face when they must fill a pain prescription for a major broken limb, when a patient has been discharged after a surgery or has another serious condition.

For example, say the doctor writes a prescription for a seven-day supply on a Monday and the pharmacist or health insurer instead limits the prescription to five days.

“The patient runs out Friday evening, and since no one can ever find their primary physicians on a weekend, the hurting patient goes to the ER, where they will not provide that person with another prescription because they did not take care of the initial problem,” the physician-patient said. “In the end, the poor patient suffers. But the doctor can get two office visits from this and the pharmacy gets two different prescriptions plus markup.”

Chu said there have been reported conflicts between pharmacists and doctors that need to be worked out.

“We passed laws to punish (offenders), but patients have chronic pain and a lot are feeling like they are criminals now” when they fill their prescription, she said.

Elizabeth Pionk, D.O., a hospitalist physician at McLaren Bay Region hospital in Bay City, said the laws have also created problems for doctors at hospitals.

“Our hospitalist group has agreed to discharge patients with two or three days of medicine, but sometimes it is difficult for patients to get a refill after they are discharged before two or three days,” said Pionk, who also is on the foundation board for the Michigan Academy of Family Physicians.

Doctors fear giving opioids to patients for more than three days because of the laws in place, Pionk said.

But that means patients who run out of pain medications will sometimes show up in the emergency room, which won’t give them medications. “The acute pain issue is a difficult one,” she said.

Shirkey acknowledged there is a problem, a “gray area between acute and chronic pain (in the bills) … and the limitations on number of doses per script.”

For example, Shirkey said, physicians may need to be able to give a patient pain medication for more than seven days if they know the patient “need(s) back surgery but cannot get into a specialist for weeks,” he said.

The medical society has received a number of other complaints about the opioid laws from patients. Among them was a patient whose doctor would no longer prescribe pain medications and sent her to a pain clinic, but the pain clinic was booked for weeks because of the new law, Chu said.

Rural Michigan faces problems as well.

Loretta Leja, M.D., a family physician in solo practice in Cheboygan, said shortages of doctors in rural northern Michigan cause people to travel hundreds of miles for primary care and surgeries. Sometimes they run out of pain medications before they can get a doctor to refill.

“I had a patient who was having major surgery downstate, and her doctor told her she could get seven days of pain medication and to come back and see him after three weeks” for a follow-up appointment, said Leja, who is chairman of the Michigan Academy of Family Physicians. “She was worried because what do you do for two weeks with no pain meds?”

Mary Marshall, M.D., a solo practicing family physician in Grand Blanc, said a growing number of her patients are coming to her when they run out of pain pills after they have had same-day surgery.

“For whatever reason the physicians or physician assistants don’t want to write more than a three-day supply of pain medications. The problem is the patient runs out,” said Marshall, who also is president of the Michigan Academy of Family Physicians.

Marshall said pharmacists and health insurers also are questioning more pain prescriptions.

“I prescribed Norco, a common opioid, and the question came up, and you have to stop what you are doing and submit information to the insurance company,” said Marshall.

The laws, and policies from pharmacies and health insurers often don’t match up, she said. “It is such a tangled web.”

Van Alstine said health insurers have used the opioid laws to deny prescriptions for palliative care patients.

“Most hospice patients receive 14-day supplies. The prior authorization process is a nightmare. Insurers are using (the laws) as an excuse to deny,” he said. “Before it was a problem, but it became more acute after the laws passed.”

For example, Van Alstine said recently he had a terminally ill patient discharged from a hospital, and he wanted to prescribe a 14-day supply of oxycontin. The pharmacist called to let him know the health insurer had denied the prescription.

“I spent four hours on a Saturday trying to get him access to medications” for pain related to liver cancer, Van Alstine said. “I filed a complaint with the insurance commissioner on Monday. They got involved and the situation was resolved, but the guy died 24 hours later. He was in pain for days before.”

Some health insurers and pharmacists have over-interpreted the laws, Chu said. “(Some health insurers) will probably use it as an opportunity to decrease utilization,” she said.

Gaedeke said she is unaware that health insurers and pharmacists are rejecting prescriptions from doctors. “They may require more visits (by patients), but we were told the laws don’t require additional visits for pain medications,” she said. “Some (pharmacists) are thinking the seven-day supply for acute pain applies for chronic pain. There is some confusion there.”

Forshee said he knows there has been confusion among physicians. Last year, Priority Health implemented new policies, which are less stringent than the state laws, that eliminated 90-day prescriptions for opioids, and limited prescription coverage to 30 days for long-acting opioids and 15 days for short-acting opioids.

“We saw there was a problem and put in requirements” that reduce the number of opioids prescribed, creates care management plans and offers additional behavioral health and medication management support, Forshee said.

Over the next three years, Priority projects a 25 percent reduction the number of prescribed opioids, Forshee said. He said the company will take another look at its policies later this year after it reviews data.

“We work closely and talk with primary care physicians, specialists like surgeons and pain-management specialists and groups to make sure our policies are based on science and evidence,” he said.

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