State sets new limits on opioid prescriptions

Local experts fear the pendulum may be swinging too far

http://www.recorder.com/News/Local/State-sets-new-limits-on-opioid-prescriptions

By TOM RELIHAN Recorder Staff
Wednesday, March 02, 2016

Here we have the state “playing doctor” on Medicaid pts.. the most sick and the poorest among us.. the least capable of defending for themselves.   Please note that those in Methadone addiction treatment are EXEMPT from any limitations.

GREENFIELD — New limits on how many opioid painkillers health care providers will be allowed to prescribe to patients who receive insurance through the state’s MassHealth Medicaid program are set to go into effect March 7, and some local experts fear the pendulum may be swinging too far to one side as government agencies struggle to bring a growing heroin and prescription drug abuse problem under control.

The state’s MassHealth program offers health care benefits directly, or by paying part or all of a recipient’s health insurance premiums. According to a recent memo from the state Department of Public Health, the program will reduce the maximum amount of morphine equivalents per day of pain medication that a patient can be prescribed from 240 to 120 milligrams.

This is the second time the limit has been lowered since April 2014, when it was 360 milligrams per day, according to MassHealth spokeswoman Michelle Hillman.

A morphine equivalent dose is a measurement used to compare the potency of different opioid medications, relative to that of morphine, to account for the different ways the body processes each drug.

Hillman said between 2,000 and 4,000 of the 1.8 million MassHealth members may be affected by the new limits.

The department cited the high number of opioid-related overdose deaths in Massachusetts over the past few years, implying a link to high dose prescriptions.

“The new high dose threshold, 120 milligrams MED, is now widely adopted in the medical community, including by the Medicare Part D prescription drug program,” Hillman said. “The threshold was established based on the lack of clinical evidence of long term efficacy of higher doses in light of clear evidence of harm.”

Hillman said providers will be able to override the limit if necessary with the department’s approval.

The changes would also place new regulations on methadone, requiring prior authorization before a person is allowed to begin taking it for pain management.

Hillman said methadone intended to be used in treating substance abuse will not be subject to the restrictions. The drug is commonly used in chemical replacement addiction therapy.

“MassHealth is implementing prior authorization for new patients on methadone when used in the management of pain because of the disproportionate number of opioid overdose deaths associated with it,” she said.

But members of the regional Opioid Task Force, which has been working since 2014 to beat back the growing opioid drug and heroin crisis, said they think the new limits may reflect efforts to stem the overprescription of opioid painkillers beginning to become excessively restrictive at the expense of patients whose conditions are truly helped by the drugs.

Task Force Director Marisa Hebble noted that many who take opioid painkillers don’t become addicted to them and use them to successfully manage chronic pain.

“You don’t want to send people in that direction, but there are a lot of people taking opioids where it’s helpful; not everyone taking them is becoming addicted,” she said. “While it’s important that we look at prescribers, it’s also important that we don’t swing too far and limit those doing well on opioids.”

Dr. Ruth Potee, a physician specializing in addiction at Valley Medical Group in Greenfield, agreed.

“For a lot of patients, their opioids allow them to function, to exercise, to take care of their grandkids,” said Potee. “The vast majority of people who take opioids chronically — like, 80 percent — get benefits from them. They’re not causing harm to themselves or society with them and they’re not addicted to them.”

Potee said most offices now require measures to be put into place to ensure patients don’t become addicted to their medication or begin abusing it. Those take the form of both randomized and routine urine drug screenings and random pill counts, among other practices.

“If you’re getting early refills, something’s wrong,” she said. “You shouldn’t be dose-escalating yourself once you’re on a stable dose.”

Potee said part of the problem is that prescribing pills is often the most available method of managing chronic pain, especially for the primarily low-income segment of the population served by MassHealth, because many insurance providers are typically willing to cover them, but are less willing to pay for other modes of therapy, including massage, acupuncture or somatic functioning healing. Other methods, like physical therapy, are often accompanied by high co-pays.

Thus, placing further limits on opioid prescribing across the board would only serve to further narrow the options chronic pain patients have to manage their symptoms, she said.

“There are so many ways in which our insurance structure in this country has sent us down this path that the only solution for chronic pain is more pills. For so many years, they’ve paid for the pills, and here we are in this situation where we recognize that’s not the only solution. Often times, offices like ours just end up eating the cost to (bring in alternative pain relief options).” she said, noting that Valley Medical has been running free Tai Chi and Yoga classes for that purpose for half a decade.

Potee said she believes the regulations are far too broad for their intended purpose.

“They pretend that these are not complicated living organisms. I see my patients that are doing well on opioids, and I think, what if I had to take that away, what is going to happen to these people?” she said, noting the challenges of trying to wean people down from their current doses over just two months.

MassHealth maintained that the new limits are appropriate for maintaining a balance between access to opioids for pain management and patient safety.

“Given the extent of the opiate crisis in Massachusetts and the emerging standards for safe prescribing, these changes reflect appropriate access to opioids with increased attention on the safety of high doses,” Hillman said.

You can reach Tom Relihan at: trelihan@recorder.com
or 413-772-0261, ext. 264

Filed under: General Problems