Mississippi’s proposed regulations intended to curb the opioid crisis aren’t final, but some doctors have already started drug testing patients — the cost of which can fall on the patient.

And it’s not just patients on opioids being tested. The proposed regs also cover benzodiazepines like Xanax, Klonopon, Valium and Ativan, used to treat anxiety disorders, insomnia and seizures.

Benzodiazepines are present in roughly one-third of opioid overdoses, which are killing nearly 100 Americans a day, and the combination of the two is particularly dangerous.

While the medical community grapples with shifting attitudes surrounding the prescription of benzodiazepines, some question the burden new regulations might pose for the 264,895 Mississippians currently prescribed these addictive drugs.

More: With 175 Americans dying a day, what are the solutions to the opioid epidemic?

$57 to pee

Before prescribing routine medication, MEA Medical Clinic in Jackson charged a patient $57 out of pocket for a drug test conducted by a contract diagnostic company, LabCorp, in January.

This is despite the fact the State Board of Medical Licensure is still drafting the new regulations.

As proposed, the new regulations only require physicians any time they write a benzodiazepine prescription to conduct a point-of-service urine drug test — which does not require diagnostics from an outside lab like LabCorp.

The latest draft of the regulations would also require patients prescribed benzodiazepines to visit their doctor every four months (at first it was every 90 days), at which point staff must check the Mississippi Prescription Monitoring Program.

MEA Primary Care Plus Medical Director Gene Loper told the Clarion Ledger that MEA headquarters has not given physicians any directive to begin drug testing patients on benzodiazepines, so individual physicians doing so have chosen to do so on their own.

The $57 the patient was charged for the drug test in January is in line with what MEA has estimated it will cost to comply with new regulations, Loper said.

“I don’t think that’s what the licensure board intended for this to be, but that’s the consequence of it,” Loper said. “It’s a monetary expense to the patient. We don’t want our patients to incur that but we don’t have any direction on this.”

Licensure board member Dr. Randy Easterling said the drug test is necessary because the prescription monitoring system only goes so far. Someone could be getting drugs from the street, which wouldn’t show up as a prescription. 

“If they’re on benzos chronically, you don’t know that they’re not on opioids unless they’re tested in some way,” Easterling said.

A September report from QuestDiagnostic, a contract laboratory and diagnostic service, shows over half of Americans misused their prescription medications between 2011 and 2016, according to an analysis of 3.4 million prescription monitoring lab tests.

Of 33,000 samples tested for opioids and benzodiazepines in 2016, over one in five tested positive for the risky combination.

But the cost of the drug test, and who’s responsible for paying, illustrates the complexity of the current health care landscape. Add in each doctor’s interpretation of  rules and how they implement them, and the impact on the patient can vary greatly.

Cost variation

The clinic where Easterling practices pays $3.85 for a point-of-service urine test that screens for 10 to 12 drugs. But the clinic charges insurance companies $50, and Blue Cross Blue Shield, for example, agrees to pay $14.

“This is routine in medicine,” Easterling said of overcharging insurance companies only to accept a much lower payment. “It doesn’t make any sense.”

There is some overhead considering the time it might take a patient to take the test and the staffing required to read it, but even at the $14 insurance rate, the clinic takes in 73 percent.

Even if patients paid $15 for each test, amounting to an extra $45 a year, Easterling said it would be a small price “if doing this helps prevent some people from dying.”

More: Stop the legal fights and curb the opioid epidemic, judge says

QuestDiagnostic charges $250 for a nine-panel, point-of-service drug test. The cost of “confirmatory” drug testing, not required by the proposed regulations, is significantly more expensive because it requires additional diagnostics. At Quest, the cost shoots up to $769.

Medicaid pays for medically necessary drug tests at rates ranging from $72 to $228. It does not cover over-the-counter drug tests like the ones that would be required under the proposed regulations.

The proposed regulations do not include specific directions on which urine drug test to use, but require they test for, “at a minimum, for opioids, benzodiazepines, amphetamines, cocaine and cannabis.” Inpatient and hospice treatment is exempt from the drug test requirement.

Loper said MEA is still trying to determine whether an in-house drug test will satisfy proposed regulations or if they will have to send it off to a lab at a greater cost.

“Those are things that, quite frankly, I think need to be worked through that have not been worked through with some of these proposals out there right now,” Loper said.

For anyone charged significantly above the cost of the $5 drug test, licensure board President Dr. Charles Miles said: “I would encourage them to ask why it’s so much.”

More: How the FDA helped pave the way for an opioid epidemic

Questions about the variations in health care costs aside, some private practice psychiatrists are concerned their offices are not equipped to conduct urine testing.

Miles said the point-of-service test amounts to “putting some urine in a cup, shaking it around and writing down what it tells you.”

Beyond logistical issues, others are worried folks seeking psychiatric treatment might be deterred from seeing a doctor if they know they will be drug tested.

Confusion, misinformation

The proposed regulation changes have caused anxiety among the medical community and prompted what some call an overreaction from physicians.

“I’ve had people come to me — they have been to other doctors — because all of a sudden they’ve been cut back on their ADHD medicine because of what’s coming down,” said Jackson psychiatrist Dr. Richard Rhoden. “People are worried about their licenses — that’s their career, their livelihood. So what’s going to happen is some doctors are not even going to take these patients.”

But the proposed regulations don’t make any changes to the prescribing of amphetamines or other types of ADHD medication — that’s just another misconception.

Lawmakers did introduce House Bill 131 and Senate Bill 2817 this session requiring doctors to check the Mississippi Prescription Monitoring Program before prescribing a large swath of medication, including cough suppressants like codeine. The bills died without any fanfare.

The board has said repeatedly that it is not trying to prohibit opioid or benzodiazepine prescriptions, as long as they’re prescribed appropriately and in a way that identifies if they’re being abused.

What’s more, nothing in the proposed regulations requires doctors to cut off patients using these medications.

Much of the public controversy surrounding the licensure board’s action is less about attempts to curb overprescribing and more a result of widespread confusion and misinformation about the state’s approach to addressing the opioid crisis — like conflation between the regulations and state statute.

Mississippi law enforcement agencies have been involved in addressing the epidemic, but regulations by the Medical Licensure Board are not laws. They are rules physicians must follow or risk losing their license. The rules only apply to physicians licensed by the board, not other prescribers like dentists.

No bills to change the state statute regarding the prescription of painkillers or anxiety medication remain alive this session.

Cousin Xanax

Dr. William Rosenblatt, who called Xanax the “first cousin” of opioids, said when he came to Mississippi from New Hampshire, he was surprised at how often doctors here prescribe benzodiazapines — 1,312,976 prescriptions written in 2017.

“The question people don’t seem to be asking is why is this number of people on benzodiazepines?” he said. “Let’s not forget that benzos are not first-line drugs for anxiety or insomnia.”

Rosenblatt said he sees patients everyday who have been taking Xanax and were never told of its addictive nature or even about alternatives.

“They often greet me with open arms when I tell them there are other options,” he said. 

If the new regulations should accomplish anything, Rosenblatt said, it’s to get doctors to think twice when prescribing benzodiazepines and consider alternatives like anti-depressants.

Of course, Rosenblatt said, some people with severe anxiety and panic disorders will benefit from remaining on drugs like Xanax, but those make up a small percentage of the more than 250,000 Mississippians on them now.

Rosenblatt also said the proposed regulations present no more of an inconvenience than what many ADHD patients currently face. (Some doctors choose to drug test patients prescribed Adderall or other amphetamines to ensure they’re taking their medication, though it’s not required by the regulations).

“Until we get rid of that (overprescribing) situation and figure out how to appropriately treat anxiety disorder, I don’t think we can then talk seriously about the inconvenience of a drug test,” he said.

The proposed regulations don’t specify how doctors are to move forward if a patient’s drug test comes back positive for other potentially harmful medications, to much consternation from doctors. Miles said it’s supposed to prompt a conversation. 

“I can sit down with someone if the drug screening shows a combination of drugs in their urine that could be lethal. I’d say what have you been on that I haven’t known about. Let’s talk about what medication you’re on,” Miles said. “You can’t stop anybody from being on it, but if you don’t know they’re on something, you can’t sit down.”