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Opioid laws hit physicians, patients in unintended ways

New state laws on opioids intended to save lives have physicians complaining about unintended consequences.

None of the doctors interviewed by Crain's objected to the laws' intent: Reducing misuse of the powerful painkillers that have contributed to rising deaths and addictions.

But they say regulations have added unnecessary administrative headaches, led to a climate of fear for doctors and left patients unable to get medications when they really need them.

Doctors also say some health insurers are using the laws to inappropriately deny or delay prescriptions, sometimes even for patients with cancer and terminal illness. Some pharmacists are also making it harder to get prescriptions filled in ways that go beyond the law, the physicians say.

A number of doctors told Crain's they have voluntarily limited the number of opioid prescriptions they write for patients because they fear they might be arrested or disciplined for overprescribing. One physician gave up his DEA license because he didn't want to learn all the new rules or risk breaking the law.


Betty Chu, M.D., president of the Michigan State Medical Society Betty Chu, M.D., president of the Michigan State Medical Society
Doctors who include Betty Chu, M.D., president of the Michigan State Medical Society, and Chris Bush, M.D., a family practice physician in Riverview affiliated with Henry Ford Health System, say legislators and the state Department of Licensing and Regulatory Affairs need to listen to doctors and correct the problems.

"We are hoping that LARA (and legislators) work with us and multiple other stakeholders to fix the laws and improve stakeholders' goals: reducing deaths and improve patients' health," Chu said.

Kim Gaedeke, deputy director with LARA, said the department is working with providers to address problems.

"There also is misunderstanding with these laws," said Gaedeke, adding: "The message has been really been letting providers know we are all in it together. We have a mutual mission, including our law enforcement partners, to protect health and welfare of citizens."

Gaedeke said LARA issued an earlier this month to answer some physician and pharmacist questions and address unintended effects related to pharmacies and health insurers.

One big concern is that laws making it more difficult to get prescription drugs could be pushing addicts and some patients into buying heroin or other drugs on the street, Chu and Bush agree.

And that includes black-market prescription drugs. Because prescription drugs for chronic diseases such as diabetes cost so much, some normally law-abiding patients sell their opioid prescriptions to be able to buy insulin or even food, doctors and state officials tell Crain's.

As a result, the number of deaths and addictions hasn't appreciably changed the past several years in Michigan, physicians and state officials say.

Nationally, more than 115 people die per day of opioid overdoses. Prescription opioids are powerful pain-reducing medications such as Vicodin or morphine. Illegal opioids include heroin, illegally produced fentanyl and an array of synthetic substances.

In Michigan, opioid deaths and overdoses rank 18th-highest in the nation. In 2016, 2,356 people died of drug overdoses, about six per day, more deaths than from car accidents.

Many health systems are prescribing fewer opioids. It's less clear that has done anything to slow the epidemic.

While Chu said she hasn't seen any data showing reduced deaths, Henry Ford Health has tracked a 40 percent reduction in opioid prescriptions the past five years. Chu is vice president of medical affairs at Henry Ford West Bloomfield Hospital.

"Deaths have not gone down, because of the issue of illicit drugs," Chu said. "As prescribing has gone down, people still deal with pain."

Chu said more discussion needs to be directed to non-pharmacy pain resources to help patients. "It's not like people don't have pain anymore. They do. There are patients who need something. We as doctors are not just responsible for managing opioid prescriptions, but to manage patient care and pain."

But Chu said over the past several months the medical society has been getting "a ton of feedback" from physicians and patients about the negative effects of the new laws.

"We are hearing a lot from (doctors) about patients who are suffering because of the laws. We recognize the pressure the legislature had to do something, but ... some of the provisions have been very challenging," Chu said.

State Sen. Mike Shirkey, chairman of the Senate health policy committee, said the Legislature will look at tweaking the bills to fix any problems.

"We have to be patient and avoid reacting to resistance to change versus resistance to unnecessary or non-value-adding regulation," Shirkey said.


Provider conflicts

Chris Bush, M.D., a family practice physician in Riverview affiliated with Henry Ford Health System Chris Bush, M.D., a family practice physician in Riverview affiliated with Henry Ford Health System
Bush said doctors have told him the new opioid laws are creating additional conflict between prescribers, pharmacists and health insurance companies over correct dosages.

"The bills are mostly good, but legislators took a heavy-handed approach to the crisis, and the result may not have a big effect on opioid" deaths and addictions, Bush said.

For example, one patient who is also a physician, who asked for anonymity, was prescribed a seven-day supply of the painkiller Norco from her doctor, 28 pills. However, the health insurer denied the prescription for 28 pills and allowed only 20 to be filled. The insurer had recently changed its policy to limit opioid prescriptions for acute pain to five days, even though the laws allow for seven.

"How did the pharmacist know it was for acute pain and not chronic pain?" the physician-patient said. "The bottle wasn't marked."

"When I challenged with the fact that the state law now gives pharmacists the ability to do split opioid prescriptions, he said that wasn't what" the pharmacy does, the physician-patient said. "Clearly, (the pharmacy) is making money."

Beginning March 27, Michigan law allows pharmacists to fill Schedule 2 controlled substances in increments to avoid making the patient go back to the doctor.

Dianne Malburg, COO of the Michigan Pharmacists Association, said there is confusion with some of the opioid laws between doctors and pharmacists. She said common questions from pharmacies range from whether to allow partial refills and whether the prescription was intended for acute or chronic pain.

"We have heard some physicians write two scripts for patients and predate them so patients don't have to go back again," Malburg said.

On partial refills, Malburg said patients can't get the whole prescription filled the same day if there is a limit from the health insurer or state law. "They can come back and get the remainder" when the initial fill has run out, she said.

Pharmacists are concerned they might not know if a prescription is for acute or chronic pain, Malburg said. State law limits opioids to a seven-day supply for acute pain, but prescriptions for chronic pain can be longer.


Problems with limits

Beginning June 1, Public Act 248 of 2017 requires physicians who want to issue a prescription for more than three days to first check with the Michigan Automated Prescription System, that houses information on prescriptions for opioid and other controlled substances. The act excludes prescriptions written for a patient in a hospital or ambulatory surgery center.

Fred Van Alstine, M.D., a family physician in Traverse City who specializes in palliative care and is a hospice medical director, said there also should be exceptions in opioid laws for hospice patients and those in palliative care who are dying.

"This was a solution looking for a problem. ... It is an administrative burden because our patients are end of life and they need" opioids to control pain, Van Alstine said.

James Forshee, M.D., Priority Health's chief medical officer, said his company's prior-authorization rules on opioids exempt patients in palliative care, hospice or in cancer treatment.

"The whole effort of the law is to reduce opioid use, prevent addiction, misuse and abuse," Forshee said. "That is not an issue with palliative care and hospice treatment. Pain control is the primary purpose."

Bush said the opioid laws' blanket restrictions illustrates the quandary physicians sometimes face when they must fill a pain prescription for a major broken limb, when a patient has been discharged after a surgery or has another serious condition.

For example, say the doctor writes a prescription for a seven-day supply on a Monday and the pharmacist or health insurer instead limits the prescription to five days.

"The patient runs out Friday evening, and since no one can ever find their primary physicians on a weekend, the hurting patient goes to the ER, where they will not provide that person with another prescription because they did not take care of the initial problem," the physician-patient said. "In the end, the poor patient suffers. But the doctor can get two office visits from this and the pharmacy gets two different prescriptions markup."

Chu said there have been reported conflicts between pharmacists and doctors that need to be worked out.

"We passed laws to punish (offenders), but patients have chronic pain and a lot are feeling like they are criminals now" when they fill their prescription, she said.

Elizabeth Pionk, D.O., a hospitalist physician at McLaren Bay Region hospital in Bay City, said the laws have also created problems for doctors at hospitals.

"Our hospitalist group has agreed to discharge patients with two or three days of medicine, but sometimes it is difficult for patients to get a refill after they are discharged before two or three days," said Pionk, who also is on the foundation board for the Michigan Academy of Family Physicians.

Doctors fear giving opioids to patients for more than three days because of the laws in place, Pionk said.

But that means patients who run out of pain medications will sometimes show up in the emergency room, which won't give them medications. "The acute pain issue is a difficult one," she said.

Shirkey acknowledged there is a problem, a "gray area between acute and chronic pain (in the bills) ... and the limitations on number of doses per script."

For example, Shirkey said, physicians may need to be able to give a patient pain medication for more than seven days if they know the patient "need(s) back surgery but cannot get into a specialist for weeks," he said.

The medical society has received a number of other complaints about the opioid laws from patients. Among them was a patient whose doctor would no longer prescribe pain medications and sent her to a pain clinic, but the pain clinic was booked for weeks because of the new law, Chu said.

Rural Michigan faces problems as well.

Loretta Leja, M.D., a family physician in solo practice in Cheboygan, said shortages of doctors in rural northern Michigan cause people to travel hundreds of miles for primary care and surgeries. Sometimes they run out of pain medications before they can get a doctor to refill.

"I had a patient who was having major surgery downstate, and her doctor told her she could get seven days of pain medication and to come back and see him after three weeks" for a follow-up appointment, said Leja, who is chairman of the Michigan Academy of Family Physicians. "She was worried because what do you do for two weeks with no pain meds?"

Mary Marshall, M.D., a solo practicing family physician in Grand Blanc, said a growing number of her patients are coming to her when they run out of pain pills after they have had same-day surgery.

"For whatever reason the physicians or physician assistants don't want to write more than a three-day supply of pain medications. The problem is the patient runs out," said Marshall, who also is president of the Michigan Academy of Family Physicians.

Marshall said pharmacists and health insurers also are questioning more pain prescriptions.

"I prescribed Norco, a common opioid, and the question came up, and you have to stop what you are doing and submit information to the insurance company," said Marshall.

The laws, and policies from pharmacies and health insurers often don't match up, she said. "It is such a tangled web."

Van Alstine said health insurers have used the opioid laws to deny prescriptions for palliative care patients.

"Most hospice patients receive 14-day supplies. The prior authorization process is a nightmare. Insurers are using (the laws) as an excuse to deny," he said. "Before it was a problem, but it became more acute after the laws passed."

For example, Van Alstine said recently he had a terminally ill patient discharged from a hospital, and he wanted to prescribe a 14-day supply of oxycontin. The pharmacist called to let him know the health insurer had denied the prescription.

"I spent four hours on a Saturday trying to get him access to medications" for pain related to liver cancer, Van Alstine said. "I filed a complaint with the insurance commissioner on Monday. They got involved and the situation was resolved, but the guy died 24 hours later. He was in pain for days before."

Some health insurers and pharmacists have over-interpreted the laws, Chu said. "(Some health insurers) will probably use it as an opportunity to decrease utilization," she said.

Gaedeke said she is unaware that health insurers and pharmacists are rejecting prescriptions from doctors. "They may require more visits (by patients), but we were told the laws don't require additional visits for pain medications," she said. "Some (pharmacists) are thinking the seven-day supply for acute pain applies for chronic pain. There is some confusion there."

Forshee said he knows there has been confusion among physicians. Last year, Priority Health implemented new policies, which are less stringent than the state laws, that eliminated 90-day prescriptions for opioids, and limited prescription coverage to 30 days for long-acting opioids and 15 days for short-acting opioids.

"We saw there was a problem and put in requirements" that reduce the number of opioids prescribed, creates care management plans and offers additional behavioral health and medication management support, Forshee said.

Over the next three years, Priority projects a 25 percent reduction the number of prescribed opioids, Forshee said. He said the company will take another look at its policies later this year after it reviews data.

"We work closely and talk with primary care physicians, specialists like surgeons and pain-management specialists and groups to make sure our policies are based on science and evidence," he said.


Fear of discipline

In early July, Detroit physician Zeyn Nez Seabron became one of about 53 doctors or pharmacists suspended or otherwise disciplined for overprescribing controlled substances, according to LARA.

LARA's complaint stated that during nine months in 2017 and 2018, Seabron was a top prescriber of oxycodone and oxymorphone, both commonly abused opioids.

Forshee said he can understand why doctors might hesitate to prescribe for fear of "gotcha" investigations and discipline.

But Gaedeke said LARA hopes over time the new opioid laws will help reduce the number of disciplinary actions taken against prescribers.

"Our goal is to go after the worst of the worst. Those blatantly prescribing, violating laws and causing deaths," Gaedeke said.

Chu supports the intent of LARA's crackdown. "It has been too easy to get prescriptions, but we don't want to make it too difficult for legitimate purposes," she said.

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