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Blue Cross plan targets abuse of painkillers

Dr. Lynda Young, president of the Massachusetts Medical Society, fears added paperwork could burden providers.

Amid a rising sea of addictions to prescription painkillers, Massachusetts’ largest health insurer is launching a policy to curb abuse by significantly limiting the amount of pain medication most patients can receive without prior approval from the insurer.

The program by Blue Cross Blue Shield of Massachusetts, scheduled to start July 1, will allow patients to fill a 15-day prescription and one additional 15-day supply of the most common opioid drugs, such as Percocet and Vicodin, before the insurer hits the pause button.

Future refills will trigger a Blue Cross review and the need for assurances from the prescriber that several requirements have been met, including patient counseling about the significant risk for developing an addiction, and an agreement that subsequent prescriptions will be written only by the same physician and filled at the same pharmacy or pharmacy chain to stem so-called “doctor-shopping.’’


Cancer patients and those with a terminal illness, who typically are prescribed painkillers over a long term, will be exempt from the rules.

The initiative, which insurance industry leaders say is a first in Massachusetts, is sparking concerns from the state’s largest physician trade group about the amount of paperwork it will add to already-swamped health care providers. “We don’t want the primary role of physicians to be lost by layers of administrative work,’’ said Dr. Lynda Young, president of the Massachusetts Medical Society.

Young said her organization realizes that painkiller abuse is rampant and is “ready, willing, and able’’ to work with Blue Cross on ways to make its program more manageable for physicians.

Others expressed concern that patients in pain may face undue hurdles getting treatment.

But Dr. John Fallon, Blue Cross’s chief physician executive, said the insurer spent 18 months working with specialists in pain care and addiction, and others, to develop a plan that balances patients’ needs with a mission to help stem the oversupply of drugs in the marketplace.


“The alternative is to just continue the way we have been doing this and we will have more people addicted,’’ Fallon said.

He said Blue Cross’s internal review found that more than 30,000 of its 2.8 million members received prescriptions during 2010 for short-acting opioid painkillers, such as Percocet, lasting longer than 30 days. Many specialists believe this practice increases the chances of drug misuse and dependency, and of the drugs ending up on the street.

Fewer than 3,000 members received long-acting opioids, such as OxyContin. Under the new rules, these drugs could not be prescribed without prior authorization from Blue Cross.

Blue Cross records indicate that the average length of prescribed pain treatment among its members is seven days, but the insurer believes many did not take the medicine for the duration, leading to leftover pills that could be misused by family members or sold.

State and national figures show that the number of prescriptions for painkillers has more than doubled in the past decade. And data from the federal Substance Abuse and Mental Health Services Administration indicate that Massachusetts residents are taking the drugs for nonmedical uses at a higher rate than the national average.

“There is clearly a public health issue with opiates falling into the wrong hands,’’ said Dr. Edgar Ross, medical director of pain management at Brigham and Women’s Hospital. Ross was one of the pain specialists consulted by Blue Cross while it developed its new rules.


He said he doesn’t relish the added paperwork but believes the initiative balances patients’ ability to get needed pain medication with the urgency to tighten the tap on excess drugs flowing into the market.

Other Massachusetts health insurers said they regularly monitor prescriptions among their members for suspicious activity, typically flagging patients who fill more than four prescriptions written by four prescribers at four pharmacies during a three-month period.

But no insurer had programs similar to Blue Cross’s that limit the number of pills upfront.

“There are patients who legitimately need the pain medications and we see [Blue Cross’s approach] as a barrier to care,’’ said Dr. Michael Sherman, chief medical officer at Harvard Pilgrim Health Care.

Sherman said Harvard Pilgrim is expanding its unit that investigates fraud, waste, and abuse to attack problems with painkillers and other prescription medications.

Nationally, insurers are employing a variety of approaches to curb painkiller abuse, but it is hard to know whether any are trying something similar to Blue Cross in Massachusetts, said Robert Zirkelbach, spokesman for America’s Health Insurance Plans, a national trade group.

Blue Cross medical director Dr. Jan Cook said the projected cost savings for the company from fewer prescriptions filled are relatively modest, perhaps $200,000 a year, but success in curbing addictions would save an enormous amount in avoided substance abuse treatments. She did not have a cost estimate for that.

Efforts by state leaders to curb prescription painkiller abuse have produced mixed results.


Only about 2,000 of the tens of thousands of Massachusetts providers legally allowed to prescribe the medicines have enrolled in an online prescription database created in 2010 to prevent “doctor shopping’’ by patients searching for the powerful drugs. The database allows providers to check whether a patient has received other narcotic prescriptions in the past year.

State lawmakers are considering legislation that would require providers to enroll, but softened the proposal from an earlier version ordering providers, in most cases, to first check the database before prescribing narcotic pain relievers, including oxycodone and morphine.

The new version directs the state’s Department of Public Health to create regulations stipulating who must check the database before writing prescriptions. Dr. Madeleine Biondolillo, director of the department’s agency that oversees the database, said the rules probably will target the 30 percent of providers who are responsible for writing about 90 percent of the prescriptions. “We want to make sure we are not inappropriately restricting pain medication for patients who need this,’’ Biondolillo said.

A 2010 state law requires prescribers, as a condition of license renewal, to receive training in effective pain management and identification of patients at high risk of abuse. The state’s Board of Registration in Medicine, which licenses physicians, said more than 8,000 physicians have taken an online course and at least 1,000 have attended seminars on the topic.

Kay Lazar can be reached at klazar@globe.com. Follow her on Twitter @GlobeKayLazar.