Second Opinion: Doc Says Blue Cross Opioid Policy Is Flawed

Amidst concerns over a massive national increase in the use and abuse of prescription painkillers, health insurer Blue Cross Blue Shield of Massachusetts instituted a new policy to reduce pain medication addiction and misuse.

This week The Boston Globe reports that as a result of the new policy, Blue Cross has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months.

But Daniel P. Alford, MD, an associate professor of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program at Boston University School of Medicine and Boston Medical Center, calls the policy “flawed and irresponsible.” Here’s Alford’s response:

By Dr. Daniel P. Alford
Guest Contributor

The Blue Cross Blue Shield of Massachusetts opioid management program was implemented to provide members with “appropriate pain care” and reduce the risk of opioid addiction and diversion.

In a recent Boston Globe report they claim “very significant success” with this program after 18 months because they have cut opioid prescriptions by 6.6 million pills.

Dr. Dan Alford

Dr. Dan Alford

Is this really a measure of success and if so, for whom? It likely saves Blue Cross money but has it successfully achieved their program’s stated goals? Does decreased opioid prescribing mean more appropriate pain care? Does decreased opioid prescribing reduce the risk of addiction or diversion, or does it decrease access to a specific pain medication (opioids) for treating legitimate chronic pain? Is the observed decrease in opioid prescribing evidence that opioids have been overprescribed, as Blue Cross claims, or is it proof that instituting a barrier to opioid prescribing (prior authorization) will decrease prescribing even for legitimate need? Are patients with chronic pain really benefiting from this program? I doubt it.

Adding yet more paperwork for physicians will not improve pain care, decrease addiction or the numbers of accidental overdoses from prescription opioids. Those physicians who are unwilling (or ambivalent) to prescribe opioids even when indicated will use the prior authorization requirement as an excuse to continue not prescribing. Those who are overly liberal in prescribing will figure out the most efficient way to satisfy the insurance requirements for approvals. Physicians who responsibly prescribe opioids – that is, prescribing them only when the benefits outweigh any risks — will be saddled with more administrative burdens to justify their well thought-out treatment decisions.

Some physicians may ultimately decide that prescribing opioids isn’t worth the trouble despite known benefits for some patients. Some physicians may become overwhelmed and burned out with the large number of desperate patients seeking a doctor willing to consider prescribing opioids for chronic pain.

The Blue Cross program ignores an important principle highlighted in the 2011 Institute of Medicine’s blueprint for transforming pain care in the US — chronic pain is a chronic disease. As opposed to acute pain — that is, a symptom that resolves — chronic pain persists and often gets worse over time. By requiring prior approvals to prescribe any opioid for more than 30 days, Blue Cross is assuming that chronic pain will resolve by 30 days. This is a false assumption.

As a primary care physician who manages a large number of patients suffering from chronic disabling pain, I appreciate the complexities of balancing appropriate pain management with the safe use of opioids. I understand the clinical challenges of the subjective determination of whether a patient on opioids is benefiting (i.e., improved pain control and function) or being harmed (i.e., addiction). In addition I understand the difficulties of distinguishing the patient who is inappropriately “drug seeking” due to addiction, from the patient who is appropriately pain-relief seeking, as they both can present as equally desperate for help.,

However, if Blue Cross were serious about improving my ability to manage chronic pain safely, they would increase access to new, yet more expensive, abuse-deterrent opioids (e.g., reformulated OxyContin, Opana and Embeda) rather than continuing to prefer (Tier 1) easily altered and abused opioids such as methadone and morphine.

I worry about this flawed and irresponsible policy, and that while Blue Cross congratulates itself on a job well done — decreasing the number prescriptions of opioids — we are swinging the pendulum unnecessarily too far back to the days of under-treating chronic pain in a patient population that is too often stigmatized and lacks a unified voice.

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  • JohnJB2

    My thanks to CommonHealth for disseminating this article.

    And Dr. Alford, thank you so very much for your efforts on the behalf of chronic pain patients like my brother, who is now facing severe and outrageous reductions in his desperately needed pain medications. We live in California, but the same things are happening here, in various forms.

    Obviously, widespread painkiller abuse, addiction and death is both tragic and expensive, and needs to be dealt with. And steps like making default initial prescriptions a lot smaller seem like a good idea. Lots of steps to curb unnecessary prescriptions, review cases periodically, etc. can make sense.

    But putting on up-front, blanket coverage restrictions is a blatant, callous way to save money, and to heck with the people like my brother, who is in endless pain, and is now doomed to a lot more of it.

    I’m very upset about my health insurance doubling in cost over the last 5 years, and my own small business had major trouble with benefits costs – but this is not an ethical way to address that cost problem, or widespread addiction. And are some of the people commenting here so willing to risk themselves, or their loved ones, being caught in the jaws of this draconian rule change after an accident or illness?

    I’m also saddened at the poor reading skills of several people commenting here, such as the ones who criticize Dr. Alford for ignoring the role of educating doctors about painkillers — without even bothering to read in this story that he’s the Director of the “Safe and Competent Opioid Prescribing Education (SCOPE of Pain)” Program at Boston University School of Medicine!

  • Argentus

    …and our illustrious governor is now arbitrarily banning Zohydro, which, in essence, is no worse than Oxycontin. …Except that Oxycontin gives me hiccups and makes me itchy, and hydrocodone (Zohydro, Vicodin, Vicoprofen) does not, so I was forced to take medicine with extra, unneeded painkillers in it after my recent surgery. My liver thanks you, Dr. Patrick.

    Our society has gone insane at trying to prevent drug addiction. I have to present my drivers license and sign my name at Wal-Mart to get sudafed. Really!? Sorry that I like to breathe through my nose. If people want to get high, they will do it, no matter what laws are in place. They’ll grow herbs, they’ll sniff aerosol cans, they’ll even drink gasoline. Why make it so hard for us law-abiding folks?

  • davidbecker2

    Dr Alord- how unconvincing. If you care about people in pain-they maybe you should call for doctors to be required to have education in pain care- for lack of education in pain care is the most mentioned barrier to improving pain care. I guess you didn’t review research on opioids- there is a lack of evidence for opioids for chronic pain. Oh and did anyone tell you opioids can spread breast cancer, lower immunity, cause depression, obesity, neural tube defects, sleep apnea, opioid induced neurotoxicity, endocrinopathies. Like most doctors you are ignorant and in need of education in pain care. Its ashame you don’t know about frequency specific microcurrent, calmare, noesitherapy, smr neurofeedback for pain- but isn’t that par for the course in medicine.

  • Nancy

    http://www.psychologytoday.com/blog/sleeping-angels/201206/painful-bureaucracy-in-the-most-literal-sense

    Unless you have lived with daily, debilitating chronic (& acute) pain from an incurable medical condition, you just don’t have a CLUE…

    Thank you, Dr. Alford. I can’t begin to tell you how scary it is to see the pendulum swinging back too far again. Shame on BSBS of MA.

  • Jim Smith

    Isn’t this rich — doctors fighting over an issue that was… wait for it… created by doctors!

    Hey dr. alford, here’s a news flash, pain pills aren’t prescribed by health insurance companies. They are given out by doctors. In trying to help fix one problem — the under-treatment of pain — doctors have created a public health mess, which you don’t seem to even acknowledge in your posts. Is your point that their aren’t enough pain pills on the market? What world are you living in???

    I own a small business and my health insurance costs go up every single year. I don’t have Blue Cross because it’s too expensive, but your screed against them, which pretty much amounts to “shut up and pay” for whatever we doctors prescribe — including more expensive pain pills — rings a little hollow here. Who do you think pays for those things? Have you ever met a payroll and looked at that monthly bill from a health insurance company?

    I get it — doctors don’t like to be questioned be it from patients or from health insurance companies. But, I think one of the biggest problems in health care today is this paternalistic sense that doctors know best. On this issue, I think doctors and the whole medical community have failed miserably.

    And I looked at your website at the link above. On it you acknowledge that the pharmaceutical industry pays for your program. I really don’t have a problem with that because they share some of blame for pushing these pills too. But do any of those companies that provide you your educational grant make the pills you want Blue Cross to pay for? Just wondering.

  • Helmut Schmidt

    Once again, Blue Cross Blue Shield of Massachusetts has painted lipstick on a pigs lips. Has anyone else noticed how with each reduction in benefits that Blue Cross Blue Shield of Massachusetts makes, they purport that the reduction in benefits is in the “best interest of patients.” How the Massachusetts Legislature has allowed Blue Cross Blue Shield of Massachusetts to implement their “high cost hospital/low cost hospital model” is beyond me. I’d venture to bet that either Blue Cross Blue Shield of Massachusetts has blown smoke in the eyes of the Massachusetts Legislators or the Massachusetts Legislature is not paying attention to the antics of Blue Cross and Blue Shield of Massachusetts. Now, in terms of a Blue Cross Blue Shield administrative Medical Director advocating for a potentially cost savings policy for Blue Cross Blue Shield of Massachusetts, I’m certain they’ll always be a physician who is willing to sell their soul to the ranks of Blue Cross Blue Shield of Massachusetts payroll. Speaking of Blue Cross Blue Shield of Massachusetts payroll, be reminded that the President of Blue Cross Blue Shield of Massachusetts, Andrew Dreyfuss, is reportedly earning over a million dollars a year. Remember that, the next time Blue Cross Blue Shield of Massachusetts denies you a benefit, or attempts to again paint lipstick on a pig’s lips.

    • Jim Smith

      Knee-jerk much? You’re looking at this through the wrong end of the telescope. More pain pills are not the answer — brianne has it right in her comment below. Keep whistling past the problem.

      • Helmut Schmidt

        Pain Killers are not an issue for me, as the strongest one that I’ve taken is Tylenol (or Motrin). But, Blue Cross Blue Shield of Massachusetts monkeying around with benefits is my issue. Thank God there’s Harvard Pilgrim!

        • Jim Smith

          Okay, well when you get ready to look past your own self interest let us know. And, when you get to work in Wellesley on Monday, check out the google on “public health and painkillers” and you’ll see it’s kind of a big deal. Nighty Night!

  • gossipy

    Excellent article. Perhaps instead of making this more difficult for providers, and defending BCBS, Dr. Fallon should place his efforts in educating the medical professionals who write the prescriptions, and for BCBS to research the reasons for addiction. Something I’ve not seen anything written about is whether some individuals simply have a higher propensity for addiction. Is this something that exists and are there ways to circumvent it? Let’s see some substantive research and remedies, rather than band-aids.

  • Dr. John Fallon

    Dr. Alford,

    Thank you for your post on this very important issue. Let me say at the outset that I think we clearly agree on the need to place patients at the center of all decisions regarding their medical care. We believe our Pain Medication Safety Program does just that.

    Our primary focus is to always put our members first in everything that we do. We want them to get the best care possible whatever their health needs are – and that includes treatment for pain. We designed our program with the help of outside experts in pain management, primary care and addiction services. Our approach was to develop a program that was evidence-based, and that ensured patients got all the care they need in a safe and effective manner.

    Also, it’s important to note that we exempted patients with chronic and cancer-related pain from this program so as to not adversely impact their care.

    This initiative had its genesis in our own review that showed that the quality and safety of pain care our members were receiving could be improved. Tens of thousands of our members were receiving short-acting opioids for longer than 30 days, when, on average, most received 7 days or less. A smaller number of our members were receiving long-acting opiods for their initial prescription for acute pain, which is not recommended and can be quite dangerous. And, nearly 30,000 members were receiving daily acetaminophen dosing at near-toxic levels from combination narcotic medicines.

    We could not ignore these safety and quality problems. Furthermore, we were convinced that we could promote better care for members, while lowering the risks inherent in the use of prescription pain medications by collaborating with our network providers. Although not mentioned in your post, you no doubt agree that the amount of unneeded opioids prescribed in recent years – often sitting unused in medicine cabinets – has created a serious public health problem nationally and here in Massachusetts. From a public health perspective, reducing excess pain prescriptions in the community by 6.6 million pills without decreasing access to those with legitimate needs, is a significant achievement.

    With respect to your comment on cost, that was not the primary factor for launching the initiative. This is a quality and safety program that we believe has a preventative benefit. The greatest cost savings may come from preventing some of the human costs related to prescription painkiller addiction

    To be clear, this effort is not the only answer to the problems we face with painkiller and opioid addiction. However, we believe that health plans can and should play a meaningful role in what is a community-wide problem.

    Sincerely,


    Dr. John Fallon

    Chief Physician Executive

    Blue Cross Blue Shield of Massachusetts

    • rzimmerman

      Here’s Dr. Alford’s response:

      Dear Dr. Fallon,

      Thank you for your response to my posting. We do have the same goals of improved treatment of chronic pain and decreased prescription opioid misuse. However I believe your program is based on erroneous assumptions and is a crude tool that has the potential of severe unintended consequences such as decreasing access to opioids for patients with chronic pain who benefit from them. I also disagree on how to achieve our shared goals and how to measure success.

      How are patients with chronic pain “exempted” from your program? It appears by the way your policy is written that the prior authorization procedure is required of all long-term opioid prescription regardless of the diagnosis or indication (e.g. chronic pain). Therefore opioid treatment of chronic pain will still require the same level of added administrative burden and risks decreasing access to patients with legitimate need.

      You mention that your program is “evidence-based” but I am not aware of studies that show that requiring a prior authorization for prescribing opioids for over 30 days will improve chronic pain outcomes (pain, function, quality of life) and decrease opioid harm (addiction, overdose, diversion) without causing undue harm to patients benefiting from chronic opioid therapy. There is also an assumption that there is no, or rarely a, legitimate need for long-term short-acting opioids. However, many patients with chronic pain suffer from intermittent occasional pain and only require chronic short-acting rather than long-acting opioids. There also seems to be an assumption that clinicians are either unwilling or unable to prescribe opioids safely and competently and therefore require an administrative barrier to opioid prescribing in order to keep the community safe. Based on my experience of training thousands of clinicians as part of our Safe and Competent Opioid Prescribing Education program (www.scopeofpain.com) I find clinicians eager to be trained how to use these medications safely and effectively.

      I believe a more effective strategy for BC/BS to achieve its stated goals are to 1) make abuse deterrent opioids, despite being more expensive, “preferred” opioids, 2) invest in clinician training and public education regarding the limitations of medication-only strategies for treating chronic pain and the benefits of comprehensive pain management strategies and 3) ensure easy access to high quality, evidence-based multimodal pain treatments.

      Finally how should BC/BS measure success of their program? You state that your program has reduced excess pain prescriptions in the community without decreasing access to those with legitimate needs. How do you know that you have not deceased access for those with legitimate needs? While it is easy to count prescriptions, I would challenge you to consider more meaningful, yet more difficult to measure outcomes such as improvements in pain, function and quality of life, improvements in patient and clinician satisfaction and decreases in opioid-related harm including overdose deaths and addiction.

      Sincerely,

      Dr. Daniel Alford

      Boston University School of Medicine

      Boston Medical Center

  • brianne

    It is time for the prescribing community to begin to police itself and stop being policed by the insurance companies and the state government. we have a responsibility to our patients and our profession to speak up and hold accountable our less than ethical peers as well as standing up to challenge the bean counters who would determine pur practice