Weighing the Importance of Easing Patients’ Pain Against Possible Drug Abuse

Andrew Kitchenman | January 9, 2014 | Health Care
Doctors make case for relaxing rules on access to pain medication, but insurers cite risks

pills red and white
When doctors prescribe powerful painkillers to patients, insurers sometimes require them to try other, less-expensive drugs first – an approach that doctors and patient advocates say can lead to needless suffering.

But a proposal to prevent this from happening is raising another concern: that easing access to painkillers will worsen a growing crisis with patients becoming addicted to opioids and other powerful drugs.

The final days of the state legislative session have witnessed an intense lobbying battle over a bill, S-2088, that would require health plans for public employees, individuals and small- to medium-sized employers to pay for pain medications prescribed for doctors, without requiring patients to first try the less-powerful and less-expensive medications.

Insurers have said it’s a bad time for the Legislature to pass the bill, considering the heightened focus on misuse and abuse of prescription pain pills. The issue has been at the forefront of health policy discussions since a July report by the State Commission of Investigation, which found that some doctors were bilking Medicaid by wrongfully handing out prescription painkillers.

“This is about having some control, some checking mechanism on the use of very-often dangerous, addictive drugs,” said Ward Sanders, president of the New Jersey Association of Health Plans.

Sanders said some patients go from doctor to doctor, gathering large quantities of potentially addictive pills. While the state has a prescription-monitoring program that’s supposed to catch these cases, doctors’ participation in the program is low, Sanders said.

“I think there’s compelling evidence that we don’t live in a perfect world in which all doctors are appropriately trained on the use and the dangers of pain medication,” said Sanders, adding that allowing insurers to require less-powerful drugs therefore serves as an important safety check against that dangerous activity.

But that argument is flatly rejected by the state’s largest doctors’ group, the Medical Society of New Jersey.

Mishael Azam, the group’s chief operating officer, said the argument against the bill focusing on opioid abuse is just a diversion from the insurers’ primary concern – saving money.

She noted that not all of the expensive brand-name pain drugs that would become more readily available under the legislation are addictive opioids.

Azam suggested that the bill would instead actually reduce the risk of prescription opioids winding up in the hands of addicts, since patients who are required by insurers to first try lower-cost drugs – some of which may be opioids –wind up with unused pills from prescriptions that fail to provide relief. These unused pills are at risk of being diverted to illegal uses, she said.

Azam added that there are already state and federal limits on the number of pills that can be dispensed, and that insurers can identify improper prescriptions by tracking when patients shop for pain pills from multiple doctors.

“I really don’t think they (insurers) care about danger as much as they” care about cost, Azam said.

Sanders said similar bills have been introduced in every state in the country, with the support of pharmaceutical companies like Pfizer that stand to profit from wider use of patent-protected brand-name drugs. Only a few states have passed these measures, he said.

These concerns have resonated with some legislators, including state Sen. Joseph F. Vitale (D-Middlesex), chairman of the Senate Health, Human Services and Senior Citizens Committee. Vitale said he appreciated the intent of the bill’s sponsors, including Sen. Loretta Weinberg (D-Bergen), but said the risks raised by the bill are real.

“There’s no doubt that making opiates more readily available will put more on the street,” Vitale said. “There really needs to be a check and balance, and the very first prescription doesn’t necessarily have to be OxyContin or oxycodone or Percocet,” referring to popular and powerful opioid medications.

Vitale said similar bills “have been shopped around to different states” by drug makers. He would like to see the issue addressed as part of comprehensive legislation dealing with addiction prevention, treatment and recovery that he plans to work on in the coming year with Weinberg and other lawmakers.

Azam countered concern about pharmaceutical companies’ support by noting that similar legislation has also received support from the American Cancer Society.

“I’d like to call this the Cancer Society bill, not the Pfizer bill,” Azam said, suggesting that failure to enact the legislation would send a message that the state cares more about the administrative burden on insurers than it does about the best practice of medicine.

Ethan Hasbrouck, lobbyist for the American Cancer Society in the state, testified that the bill would reduce problems caused by insurers applying outdated rules based on large populations of patients, rather than allowing individual doctors to determine the best medication after consulting with the patient.

“Pain is a subjective feeling that is not easily and universally quantified, which is what makes the patient-doctor relationship essential in treating pain caused by cancer – and this should not be compromised by insurance companies,” Hasbrouck wrote in testimony submitted to the Senate Budget and Appropriations Committee.

Weinberg supported this point: “The bottom line of this bill is, I want my doctor to be in charge of my medical care, not the clerical people – with all due respect – in the insurance companies. If my doctor thinks I need prescription A to get me through a surgery, a trauma, whatever it may be, then that’s what I should get.”

While the total cost to insurers resulting from easier access to powerful pain drugs is unclear, state officials estimate that it would cost $5.8 million annually for the state and local governments to cover the additional cost for public and school employees.

The concern over costs is the key issue for another opponent of the bill, the New Jersey Business & Industry Association, the state’s largest employer group.

NJBIA Vice President Christine Stearns said that allowing more expensive drugs to be prescribed sooner will lead to higher insurance premiums, adding that premium increases have been the single biggest reason why 20 percent of small-business employers have dropped medical coverage. She said the bill fails to strike the right balance.