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Blue Cross cuts back on painkiller prescriptions

An 18-month effort targets opiate abuse

The state’s largest health insurer has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months as part of a campaign to curb abuse of the powerful drugs, according to executives from Blue Cross Blue Shield of Massachusetts.

That estimated reduction appears to bolster the argument made by many health workers that these narcotics have been overprescribed and too easy to obtain. The drugs are cited as a gateway to heroin, which has plagued the state recently amid a startling succession of overdoses and deaths.

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The dramatic decline in prescribed opiates such as Percocet and Vicodin followed the insurer’s decision to limit the quantity of narcotic painkillers that its members could obtain without prior approval by the insurance company, said Andrew Dreyfus, president of Blue Cross Blue Shield, who described the decrease in an interview.

Faced with concerns about a rise in opiate abuse, Blue Cross implemented changes in July 2012 that have reduced prescriptions by 20 percent for common opioids such as Percocet and 50 percent for longer-lasting drugs such as OxyContin, Dreyfus said.

The insurer released the figures after a review of the first 18 months of its program, which company executives said is the first of its kind in the state and possibly the country. “We’re one of the few, if not the only one, doing this,” Dreyfus said.

Under the program, patients now need authorization from Blue Cross for more than 30 days of painkillers such as Percocet within a two-month period. Before July 2012, this prior insurer approval was not required for short-acting opioids, which generally are effective for four to six hours.

Patients are allowed to fill a 15-day prescription and one additional 15-day supply before Blue Cross intervenes. If more medication is requested, the insurer insists that the patient be assessed for the risk of addiction and that a treatment plan be agreed upon by the prescriber and the patient.

For longer-acting painkillers such as OxyContin, whose impact lasts for 10 to 12 hours, prior authorization from the insurer is always required. This approval was not needed before the changes.

“The program has been a very significant success,” Dreyfus said.

Cancer patients are exempted, as well as clients with terminal illnesses who generally need painkillers for longer periods.

Blue Cross decided to revise its regulations after an internal review showed that more than 30,000 of its members received prescriptions lasting longer than 30 days for drugs such as Percocet and Vicodin.

Working with an advisory group, the insurer sought to confront what had become “a big supply problem,” said Dr. John A. Fallon, senior vice president and chief physician executive.

Before the initiative began, a one-month supply of Vicodin often was prescribed for the extraction of wisdom teeth, Blue Cross officials said. A lower-back injury might prompt a prescription for one month’s supply of Percocet with three refills.

Now patients may receive an initial prescription for 15 days, with only another 15-day supply allowed within two months after the wisdom-tooth procedure or the back injury.

Dr. Anton Dodek, associate chief medical director for Blue Cross, said physicians had routinely written prescriptions for larger quantities. “We were trained that way: just write 30-day prescriptions,” Dodek said.

Now, Dodek said, the mindset has changed among doctors. Prescription painkillers for problems as minor as sports injuries have led to abuse of the pills and later to devastating addictions to opiates such as heroin, which is currently cheaper to buy on the street than Percocet.

“We’re trying to cut off that pipeline,” Dodek said.

A federal study showed that a growing majority of heroin users reported having abused powerful pain relievers before turning to illicit street drugs.

Last month, Governor Deval Patrick declared a state of emergency to combat the rise in opiate overdoses.

The Blue Cross campaign is attempting to head off abuse by warning physicians when patients have received powerful painkillers from three or more prescribers within six months.

Case managers also are working among Blue Cross’s 2.8 million members to enhance access to pain-management specialists and to explore, when needed, nonnarcotic alternatives to treat pain.

Other insurers in Massachusetts said they also have safeguards to fight painkiller abuse.

Dr. David Brumley, senior medical director at Tufts Health Plan, said long- and short-lasting opiates are generally restricted to a 30-day supply. “The other piece we have is monitoring during and afterward as well,” Brumley said of prescription-drug use.

Computer algorithms raise red flags if a patient’s prescription activity ventures into a worrisome area, he said, followed by mailings or a call to a pharmacy.

Mary Wallan, a spokeswoman for Harvard Pilgrim Health Care, said dosages to patients covered by its health plan are not limited upfront, but that “the company does retrospective audits of prescriptions by physicians, pharmacies, and by individual members.”

Like Tufts Health Plan, computers at Harvard Pilgrim help flag what Wallan called the “outliers.” Once outliers are identified, she said, the company’s special investigations unit analyzes the client’s behavior for prescription abuse.

Dr. Ronald Dunlap, president of the Massachusetts Medical Society, said Blue Cross is heading in the right direction.

However, Dunlap added, he hopes that a single monitoring system can someday be implemented statewide.

“You don’t want to go into three different systems,” Dunlap said.

Dodek downplayed the extra administrative work that the new restrictions require. “Essentially, it’s not a burden unless they want to use more than 30 pills within a two-month period,” Dodek said.

Fallon said the practice of limiting prescriptions already is paying dividends, and that modifications will continue to be made as the program proceeds.

“It is going to get better,” Fallon said.

Brian MacQuarrie can be reached at macquarrie@
globe.com
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