Insurance companies pushing opiates!!!

​The NY Times and ProPublica today had an article highlighting how insurance companies/pharmacy benefits managers are exacerbating the opioid crisis 

Details:

--they analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of 2017

    --lidocaine patches require prior approval

    --only 1/3 of plans cover topical buprenorphine (Butrans), which is much less risky than other opioids

    --BUT, almost every plan covers more toxic opiates without a problem

--they highlight a woman with chronic abdominal pain, on the topical buprenorphine which worked for her, but then UnitedHealthcare (the nation's largest insurer) stopped covering the drug: they suggested "switching to a 'lower cost alternative,' such as OxyContin or extended-release morphine". Her appeal was denied. She could not get the $324/month patch, but morphine was cheaper ($29 per month) and covered without any prior approval or obstacles. [the feds/DEA consider morphine to be Schedule 2 ("high potential for abuse") vs buprenorphine which is schedule 3 ("potential for abuse less than substances in Schedule 1 or 2") a category which also includes codeine]

--Dr Thomas Frieden, who was head of CDC under Obama, noted that it is now easier for most patients to get opioids than treatment for addiction

--an earlier NY Times article found that alternative non-opioid treatments, including physical therapies, yoga, cognitive behavioral therapy may not be covered by insurers (despite the recent directive by the CDC to employ alternatives to opioids as a means to decrease the opioid epidemic), leading to more scripts for opioids which are approved without a second thought by them.... see https://www.nytimes.com/2016/06/23/business/new-ways-to-treat-pain-without-opioids-meet-resistance.html?mcubz=1 

Commentary:

--in our perverse health care system, we have some remarkable incongruities: on the one hand, pharmacy benefits managers PBMs, contracted by the different health insurers, are denying access to potentially effective non-addicting, minimal adverse effect medications (eg lidocaine) in favor of cheaper opioids (with their potential huge long-term personal costs, both monetary and social). And on the other hand, they are sometimes approving very very expensive and highly profitable cancer drugs (blog tomorrow).

--one really absurd example in our current system is that Medicaid requires prior approval before allowing prescriptions for buprenorphine (Suboxone), which is a pretty safe opioid with rare serious adverse effects (eg seizures, respiratory depression) yet will readily accept prescriptions for methadone for pain management (as well as other much more toxic opiates). And 2/3 of Medicare plans also require Suboxone prior approval. Suboxone is quite expensive (likely the reason for the prior approvals), and this also reflects another fundamental problem in our health care system: uncontrolled skyrocketing costs of drug/big pharma profits.

--I, as well as probably most practicing clinicians, have several examples of these types of drug company shenanigans, eg:

    --a 72 year old patient of mine who has pretty frequent mild to moderate abdominal pain, but has documented urticarial/angioedemic reactions to acetaminophen and NSAIDs. She has Medicare and Medicaid. I wrote a prescription for some topical medications (lidocaine, then diclofenac) which were denied by the PBM. I wrote a strong letter in the Prior Approval process, noting that my only other choice to help control her pain at this point was an opioid, which has much higher risk of adverse events, both short- and long-term. This was denied. I then wrote an even stronger letter to appeal this denial. Again rejected. And she is now on opiates....

    --and, a more frequent problem: PBM denial of topicals (lidocaine, diclofenac, etc) for localized pain, leading to more use of NSAIDs, which have lots of known toxicities and longer-term personal and monetary costs: see http://blogs.bmj.com/bmjebmspotlight/?s=NSAID&submit=Search 

--and, as per many lay press articles and prior blogs by me, perhaps the key driver to our current opioid epidemic is clinician-prescribed opioids and subsequent addiction:

    -- https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm#F1_up​ , a CDC/MMWR report from 3/17/17, finding that of the 1.3M people given a first prescription for opioids, the "rate of long-term use was relatively low (6.0% on opioids 1 year later) for persons with at least 1 day of opioid therapy, but increased to 13.5% of persons whose first episode of use was >= 8 days and to 29.9% when the first episode of use was for >=31 days."

    ​-- http://gmodestmedblogs.blogspot.com/2015/10/prescribed-opioids-and-future.html  a blog on 12th graders at low risk of addiction by a validated questionnaire, getting prescribed opiates for a clinical indication, then finding that by age 23, there was a 33% increased risk of opioid misuse

    -- http://gmodestmedblogs.blogspot.com/2017/02/opiate-prescribing-in-elderly-and.htmla blog on a recent NEJM article looking at Medicare beneficiaries seeing providers classified as either high- or low-opioid prescribers, and finding that elderly patients seeing high-opioid prescribers for what seems to be similar indications as those seeing low-opioid-prescribers had a 30% increased likelihood for long-term opioid prescriptions, as well as a higher rate of subsequent hospital encounters overall and specifically for falls or fractures.

    -- http://gmodestmedblogs.blogspot.com/2017/01/increasing-deaths-from-opioids_13.html  , reviews a prior MMWR report on increasing deaths from opioids 

will have blog tomorrow on another aspect of the issue: the remarkable uncontrolled price of cancer drugs and their over-the-top profits for drug companies.