Express Scripts' new opiate plan draws fire from physicians

Nov 06 2017

Express Scripts’ new opiate plan draws fire from physicians

A new program to limit opiate painkiller prescriptions, rolled out in September by the nation’s largest pharmacy benefits manager, has drawn criticism from physician groups.

St. Louis-based Express Scripts’ Advanced Opioid Management Program limits new opioid prescriptions to just seven days, regardless of what the physician prescription calls for. The limit applies to treatment of both acute and chronic pain. Similar to one recently introduced by CVS Caremark, the Express Scripts program does not include cancer patients or patients receiving hospice or palliative care.

Express Scripts spokesperson Jennifer Luddy told Medscape Medical News that the company tested its new measures in an in-house pilot study of more than 100,000 first-time users of opioid painkillers. The results showed a 38 percent reduction in hospitalizations and 40 percent reduction in emergency room visits in the intervention group versus control group, in six months of follow-up, the company says.

Since the pilot study, Express Scripts says it has added several other opioid management features from safe disposal practices, to new tools physicians can use at the point of care and safety checks for dispensing pharmacies.

In addition, the default prescription will be written for short-acting opioids. To prescribe long-term opioid painkillers for a new user, a physician needs prior authorization. Doctors will need to obtain that permission to continue opioid therapy longer than the initial seven days.

Some pain management specialists say the Express Scripts program interferes with physician’s ability to serve their patients. “While the intent may be to help, I think the policy is somewhat misguided in its mandatory nature,” Charles Argoff, M.D., a professor of neurology at Albany Medical College, New York, told Medscape Medical News.  “The point is, they’re practicing medicine.”

Patrice Harris, MD, who chairs the opioid task force for the American Medical Association (AMA), told the Associated Press that the program was “a one-size-fits-all approach.”

“The AMA’s take has always been that the decision about a specific treatment alternative is best left to the physician and the patient,” said Dr Harris, a member of the AMA’s board of trustees.

Express Scripts has responded, saying that the new strategies are needed to curb opiate abuse. “We actually agree the doctor-patient relationship is critical, but we had 33,000 deaths from opioids in 2015,” said Steve Miller, MD, the company’s chief medical officer, in an interview with CBS Radio. “The approach that’s been taken is not working.”

Company spokesperson Luddy contends that opioid prescribing guidelines issued by the Centers for Disease Control and Prevention (CDC) for primary-care physicians in 2016 provide a “strong foundation” for its new program. The CDC recommends that physicians should only prescribe enough pills to match the expected duration of pain, which should rarely exceed seven days. Both patients with acute pain and those with chronic pain should initially should receive short-acting opioids, the CDC says. 

Patrice Harris, M.D., an Atlanta psychiatrist who chairs the American Medical Association’s Opioids Task Force, released a statement saying doctors are already addressing the opioid epidemic.

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,” she said in the statement.

“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.”

Harris notes that the AMA recommends that physicians prescribe the lowest effective dose for the shortest possible duration for management of severe pain.

If opioids are not indicated, then we need payers and (pharmacy benefits managers) to work with physicians to ensure that patients have access to non-opioid and non-pharmacologic treatments,” Harris said. “This is critically important as more patients now are dying from heroin and illicit fentanyl than from overdoses due to prescription opioids.”