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No Reimbursement for Opioid Prescriptions in NJ Written Without Plan

Doctors would be required to document patient-safety protocol before writing scrip

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New Jersey would be the first state in the nation to hold insurance companies largely responsible for ensuring opioids are prescribed only as a last resort, under a new proposal to help curb the flow of highly addictive medicines that are fueling the state’s heroin and opiate epidemic.

A bill introduced last week by Sen. Ray Lesniak (D-Union) would prohibit an insurance company from paying for opiate-based painkillers unless a physician had signed off on a five-part patient-safety protocol designed to avoid addiction. This would include documenting that drug-free pain relief methods had failed and abiding by the federal Centers for Disease Control and Prevention guidelines for such prescriptions, crafted earlier this year in an effort to limit abuse. A limited, short-term prescription – designed to last three days or less – would be exempt from the review.

California and Texas have passed versions of the plan that are limited to workers compensation claims, Lesniak said. But his proposal would also apply to commercial health insurance, injury protection issued through auto insurance plans, and the state’s Medicaid and NJ FamilyCare programs, as well as the policies covering more than 700,000 state and local workers, he said, resulting in far more extensive protection.

“If it’s effective with workers comp, there’s no reason it wouldn’t be effective across the board,” Lesniak said. “It’s important for the doctor to really think this through -- it’s just too easy to write a prescription.”

The concept is backed by some organizations in the field, including the Partnership for a Drug-Free New Jersey and Physicians for Responsible Opioid Prescribing (PROP), a national doctors group. But Lesniak said the Medical Society of New Jersey, which represents the state’s doctors, is not in favor, something he called a “disappointment.” He has not yet received feedback from representatives of the insurance industry.

The proposal is the latest in a growing focus on stopping addiction before it starts. Experts agree that the primary source of heroin and illegal opiate addiction stems from use of painkillers that are issued legally, then diverted by others. Since 2014, more than 28,000 New Jersey residents have been admitted to treatment programs for opiate-related abuse; an estimated 5,000 have lost their live to the addiction since 2004.

Dr. Vivek Murthy, the nation’s Surgeon General, outlined a multi-pronged effort to combat addiction in August that included a suite of resources to help doctors identify alternatives to opiate-based painkillers and reduce addiction risk when they are necessary. Last spring New Jersey Gov. Chris Christie, who has championed programs to reduce addiction, linked the state’s prescription database with systems in New York and other states to help reduce regional pharmacy shopping.

State Sen. Joseph Vitale (D-Middlesex), the health committee chairman, and Majority Leader Loretta Weinberg (D-Bergen) have pushed for a bill that would require prescribing physicians to discuss with their patients the dangers of opiate painkillers and pursue alternatives, when possible. But opposition from the state medical society and Assemblyman Herb Conaway (D-Gloucester), a doctor who chairs that house’s health panel, has slowed its progress.

Lesniak said his measure incorporates many of these same goals but adds an enforcement mechanism -- “real teeth” -- in the form of a barrier to payment for opiate prescriptions that are issued without the safety protocol. “Guidelines on their own aren’t enough,” he said. “This has the hammer effect.”

Angelo Valente, executive director of the Partnership for a Drug-Free New Jersey, said awareness and education are critical to curbing abuse. “Everyone must have a role in reversing this epidemic -- including lawmakers, parents, coaches, educators, and, yes, even doctors and dentists,” he added.

The bill (S-2703) has attracted several Assembly sponsors, including Assemblywoman Shavonda Sumter (D-Passaic), who joined Lesniak and other supporters last week at Eva’s Village, a treatment facility in Paterson, to announce the plan. Details are not yet posted on the Legislature’s website, but, according to a copy provided to NJ Spotlight, the measure requires doctors to go through a check-list of safeguards before medical payers could cover the cost of opiate-based drugs.

“This is too serious of an issue not to make the medical profession and the insurance companies spend some time and take a real look” at the patient and their history, before issuing an opioid painkiller, Lesniak said.

To trigger reimbursement for such drugs, a doctor would have to perform a thorough medical history and create a decision-making plan for pain control; document that non-pharmacological pain methods have not worked; and discuss the dangers of the drugs with the patient. In addition, the physician would need to check the patient’s name in the state’s painkiller database to ensure they aren’t collecting multiple prescriptions. If opiate-based drugs were prescribed, the law would limit the dosage to the equivalent of no more than 90 milligrams of morphine per day. As drafted, the law would not apply to a three-day supply of opiates, or less.

Dr. Andrew Kolodny, the executive director of PROP, said the proposal would help prevent addiction -- in part by reducing the glut of unused pills in people’s medicine cabinets -- and ensure better pain treatment. “It will help reduce casual and inappropriate opioid prescribing,” he said. “And when opioids are necessary, the bill will help ensure that patients are carefully evaluated, adequately informed about opioid risks, and closely monitored.”

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