The Arizona Opioid Crisis: The Legitimate Patient
By Yvonne Stevens
On April, 13, 2017, Arizona Governor Doug Ducey’s office published a news release titled Applauding the Introduction of Bill to Combat Opioid Abuse. On June 5, 2017 Ducey declared a state-wide health emergency to address Arizona opioid overdoses and pushed for increasing the availability of naloxone, a drug that reverses the life-threatening effects of an opioid-related overdose. The declaration was preceded by an October 2016 Executive Order limiting state opioid prescriptions, administered by state payers, to seven days for certain users. In response, Arizona’s Medicaid Agency (AHCCCS) immediately issued policies around the seven-day opioid limitation, which took effect April 1, 2017. Yet, in the meantime, another more restrictive five-day plan was announced by Ducey on September 6, 2017. Private payers, such as Anthem Blue Cross, are also on high alert, many having their own oversight programs in place. Earlier this month, in a move criticized by the American Medical Association (AMA) and many physicians, Express Scripts, the nation’s largest pharmacy benefit manager, implemented a scheme limiting the quantity and strength of opioid medications that physicians may prescribe to first-time users.
It is clear that many have taken notice and steps to combat the abuse and misuse of opioid prescriptions. That, in itself, is not surprising: people are dying and the numbers rising. But where do such measures leave legitimate patients — and who are they? Assuming their doctors are equally legitimate, other than post-surgical patients, these are patients who are prescribed an amount necessary to combat chronic or acute pain in order to physically function, perhaps not at 100%, but at 50% to75%. They are the same patients who follow their doctors’ orders and do not abuse their maximum daily allowance. Patients who do not necessarily want to take such medications but, via a process of elimination, have determined it is the only thing that works to manage their pain.
Legitimate chronic or acute pain patients often carefully consult various specialists, including surgeons, physiatrists, chiropractors, physical therapists and acupuncturists in an attempt to find pain relief. Sometimes, patients receive conflicting advice or the suggested therapies simply do not work. Trial and error. They are prescribed opioids at some point during their medical odyssey, though are very much aware of the potential for addiction and, also, the horrible side effects that may present with withdrawal – which tend to be worse the longer the medication is consumed.
Pharmacies themselves have increased their gatekeeping role and implemented strict policies, with questionable subjective components. Equipped with time-delay safes, some are electing not to carry opioids at all or carry only limited quantities. One Arizona chronic pain patient recently attempted to refill a prescription and had to drive to eight pharmacies before finding one that stocked the prescribed opioid. Another attempted a refill on a Wednesday and was told by the on-duty pharmacy technician to return on Friday because, despite a legitimate prescription, it was two days too early to fill. Assuming it was a coverage concern, the patient offered to pay cash, but unbeknownst to him, the payer was not the issue. The big-box pharmacy technician refused cash payment (although insurance would have covered the early dispensing of the medication) and chose not to dispense it. In fact, the medication would not be released without having the patient jump through additional hurdles — hurdles that were only explained after the customer left and then drove back to the pharmacy to challenge the technician’s decision. The patient eventually received his medication several hours later, feeling stigmatized and humiliated.
There is no question the nation is experiencing an opioid crisis and action is required –until (if and when) pharmaceutical companies develop an effective, non-addicting alternative. In September 2007, Arizona H.B. 2136 (Bill), establishing a Controlled Substances Prescription Monitoring Program, took effect. The Bill required the Arizona State Board of Pharmacy to institute a controlled substances prescription monitoring program, which includes, among other things, a central digital prescribing, dispensing and consumption tracking system. This gives pharmacies a great deal of information as to who might be over-prescribing and misusing opioids — at least in cases where a prescription is involved. National pharmacy giants, Walgreens and CVS have been sanctioned for alleged lax oversight in dispensing opioids. According to one news report, Walgreens, “[A]greed to update its policies and procedures, and train its staff, to ensure that pharmacists properly monitor and do not accept cash payments from patients deemed high risk” (Boston Globe, 2016). But who is “high risk?” Was the above-described patient, with his justifiable cash offer, high risk? According to one “secret” pharmacy checklist, yes. Offers to pay cash are red flags, however innocent the offer. There are horror stories published about pharmacy treatment of legitimate patients with legitimate needs and these, likely, will not stop anytime soon. For several years the AMA has been concerned with the approach pharmacies have taken. An Indianapolis-based news source, quoting an AMA spokesman, notes that, “Physicians in more than 20 states tell the AMA that several national pharmacy chains may be inappropriately restricting patients’ access to legitimate pain medication. Such roadblocks are creating serious barriers to patient access to needed medications – including those in hospice.” (13 WTHR, 2013).
Balancing the risk of misuse against the needs of the legitimate patient, options other than a bar to access or short-term access should be considered, especially for established, long-term chronic pain patients. For instance, an indestructible time-release dispensing container could be developed, ensuring a patient cannot take more than his or her prescribed allowance. We are an innovative society, surely there are ways to curb addiction and misuse while not denying access to others legitimately coping with pain resulting from trauma, surgery or otherwise. While such patients should be properly managed (with ongoing physician oversight, checklists, regular assessments, etc.) and weaned off safely when the time is right, they should have straightforward access for extended periods to pain-relieving opioid medication, particularly when available alternatives have been exhausted and the situation is not one of abuse. Better communication between pharmacies and physicians is a must and pharmacy staff should not wield unnecessary subjective powers. The regulatory and policy pendulum has swung too far, in this case, unjustifiably making legitimate patients’ lives more stressful, challenging and painful.