Physicians speak up about patients being denied needed prescriptions
by Kate Alfano, CMS Communications Coordinator
Featured in the September-October 2019 Colorado Medicine Colorado Medicine.
Momentum is building in the effort to combat the opioid epidemic, and physicians and other stakeholders, especially in Colorado, should celebrate this progress. But as opioid restriction policies have increased, physicians – especially those specializing in oncology and palliative care – report that their patients face unnecessary barriers to filling the prescriptions they need for pain management.
“It’s a huge problem for our patients,” said Sami Diab, MD, a physician who is board certified in medical oncology, supportive oncology and palliative care. “They get short on their pain medications, and the pharmacy says they cannot fill the prescription before a certain date or they cannot give them the prescribed number of pills.”
Though uncertain whether the barriers originate with pharmacy chains with overarching corporate policies limiting opioids or certain payers’ policies, Diab says he receives at least an email a week from a frustrated patient or caregiver who has been turned away at the pharmacy counter.
“If you look at the problems and statistics on the national level, you realize that it’s not an issue isolated to Colorado or one pharmacy,” Diab continued. “It’s a national issue where cancer patients are caught in the crossfire with [efforts to stem] narcotics and opioid overdose and all the new regulations to address them in the general population for good reasons.”
“Previously the pendulum swung away from treating cancer pain and patients suffered immensely,” said Eleanor Jensen, DO, a palliative care physician with Kaiser Permanente. “Then, the pendulum swung back and all pain was treated with opioids. I think there is real PTSD in the medical community, particularly in oncology, around returning to a time where our most fragile patients don’t have appropriate access to opioid pain management. That being said, I also think that if we – practitioners who support patients with cancer – insulate ourselves and have an open prescription pad policy for all cancer patients that there will be a subset of patients who are not well managed and will suffer as others have from too much access to opioids and particularly benzodiazepines.”
“When patients have been on high-dose opioids for chronic pain, it makes treating their pain at the end of life very difficult and they suffer more than many other patients – this is a real reason to help minimize opioids in the general population,” Jensen said. “I am grateful that I’m able to help patients manage their symptoms in order to meet their goals. At the end of the day, I think this should be the framework for everything we do – goal-oriented care.”
As the Centers for Disease Control and Prevention clarified in February, their Guideline for Prescribing Opioids for Chronic Pain is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management. “CDC encourages physicians to continue to use their clinical judgment and base treatment on what they know about their patients, including the use of opioids if determined to be the best course of treatment.”
The American Medical Association responded to the CDC in April with a statement by AMA President Patrice Harris, MD: “The AMA appreciates that the CDC recognizes that patients in pain require individualized care. … The guidelines have been treated as hard and fast rules, leaving physicians unable to offer the best care for their patients. … [They] have been misapplied so widely that it will be a challenge to undo the damage. The AMA is urging a detailed regulatory review of formulary and benefit design by payers and pharmacy benefit managers to ensure that patients have affordable, timely access to medically appropriate treatment, pharmacologic and non-pharmacologic.”
In Colorado, the General Assembly passed a law in 2018 limiting initial prescriptions to seven days for patients who have not had an opioid prescription in 12 months by that physician, with exceptions for patients who have been diagnosed with cancer or are experiencing cancer-related pain, or who are undergoing palliative care or hospice care focused on providing the patient with relief from symptoms to improve quality of life. This restriction is scheduled to repeal in September 2021.
Additional Colorado Medicaid policies limit morphine equivalents and pill quantities for beneficiaries. Patients currently on a pain management regimen are limited to daily morphine milligram equivalents of 200 MME per day. Medicaid’s pill quantity limits apply to short-acting opioids, allowing a maximum of four tablets per day or 120 tablets per 30 days.
“There’s an opportunity for the legislature, whenever they are passing any new laws, to think about the impact of this on terminal patients; consider the impact on access for patients who legitimately need pain medications, whether it’s hospice or cancer patients getting active treatment for advanced cancer,” Diab said.
Any physician whose patients are having difficulty filling opioid prescriptions should contact the Colorado Consortium for Prescription Drug Abuse Prevention. Staff is tracking the issue and will act as needed.