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Major health insurance company limits pain pills in attempt to prevent drug abuse

Posted at 7:26 PM, Aug 17, 2017
and last updated 2017-08-17 22:49:12-04

Doctors are worried about a new effort in the works that will limit the number and strength of pain pills for hundreds of thousands of patients.

With 83 million members, Express Scripts is the largest pharmacy benefit manager in the country.  On Sept. 1, Express Scripts will fully implement a nationwide program because they say the time has come for bold action to stop drug abuse before it begins. 

The company says its goal is "to help people get the medicine they need, without getting more than they need."

Their effort is focused on first-time opioid prescriptions, but will not apply to cancer or hospice patients.  

The program will limit impacted patients to a 7-day supply and a total daily dose limit.  Express Scripts will advise doctors to prescribe short-acting drugs as opposed to the extended-release versions. 

But the program does allow doctors to get authorization beyond those limits.

In a pilot study of 100,000 members, Express Scripts says the new program has reduced hospitalizations and emergency room visits by up to 40 percent. 

Contact 13 asked the American Medical Association for their thoughts on the program.  They provided the following statement:

“When patients seek physician help for an opioid use disorder-or need comprehensive care for chronic pain-one-size fits all limits, such as blanket prior authorization protocols, may cause delays in care that could severely harm patients. While physicians continue to make important strides in making more judicious prescribing decisions-evidenced by the 17 percent nationwide decrease in opioid prescriptions since 2012-it is critical that we prescribe opioids only when the benefits outweigh the risks. If prescription opioids are indicated, we recommend that physicians prescribe the lowest effective dose for the shortest possible duration for pain severe enough to require opioids. If opioids are not indicated, then we need payers and PBMs to work with physicians to ensure that patients have access to non-opioid and non-pharmacologic treatments. This is critically important as more patients now are dying from heroin and illicit fentanyl than from overdoses due to prescription opioids.”

Dr. Patrice A. Harris, immediate past chair of the AMA Board of Trustees and chair of the AMA Opioid Task Force