Express Scripts’ New Program Limiting Opioids Stirs Controversy Within the Physician Community

The nation’s largest Pharmacy Benefit Manager (PBM), Express Scripts (ESI), has launched a new nationwide program that aims to curb opioid prescriptions that are both written by physicians and dispensed by pharmacies. This new ESI program has sparked comments by many physicians, including pain-management specialists, who claim that ESI’s program usurps the clinical judgment of physicians for their patients. 

ESI’s program will limit patients who are new to opioid therapy to an initial 7-day supply for their first opioid prescription irrespective of whether the patient’s pain is acute or chronic and irrespective of what the physician’s prescription states.

Further, ESI’s program, will require a first-time opioid user to use short-acting opioids, unless the patient’s physician obtains prior authorization for long-acting opioids. A prior authorization will also be necessary for continuing opioid therapy beyond the initial 7-day prescription, and a daily dosage limit of no more than 200 mg of a morphine equivalent dose (MED) per day. If the physician in his or her clinical judgment believes that the patient needs additional medication beyond the 200 mg MED per day, then the physician will need to obtain a prior authorization.

With these prescription restrictions and prior authorization requirements, there is no doubt that there are many obstacles for physicians to order opioids and will add further challenges for patients to obtain opioids. One of the major issues that arises, is that ESI’s program may unduly burden patients who truly need opioids, while not substantially reducing access to those individuals that are abusing opioids.

For some physicians, however, another issue arises, which includes concerns that ESI is practicing medicine and usurping the physician’s independent clinical judgment. Charles Argoff, MD, a professor of neurology at Albany Medical College, in an interview with Medscape Medical News, stated, “While the intent may be to help, I think the policy is somewhat misguided in its mandatory nature.  The point is, they’re [ESI] practicing medicine.”

Patrice Harris, MD, who chairs the opioid task force for the American Medical Association (AMA), stated, “The AMA’s take has always been that the decision about a specific treatment alternative is best left to the physician and the patient.”

ESI does not deny that the physician-patient relationship is a critical component, and feels its prior authorization process does not close the door to physician discretion, however ESI, also acknowledges that there are many deaths related to opioids each year, and that a different approach to the opioid epidemic is warranted. ESI is not the first PBM to implement a program such as this one, CVS Caremark, has also similarly initiated a program similar to ESI’s program.

Some physicians are nevertheless skeptical about ESI’s motives; worry about the administrative hassles that ESI’s program may create; and are concerned the program is not evidence based and may not achieve the opioid prescribing and dispensing goals it aims to curb. 

Yet, other physicians do acknowledge potential problems with opioids and as stated by Dr. Stanos, “The problem with excessive amounts of opioids is that patients don’t use all the pills, and they end up in the medicine cabinet. Then someone abuses them or diverts them to the street.”

With all the unrest with opioid prescribing, dispensing, and consuming, and how best to manage the current opioid national epidemic, the one thing that seems certain is that the topic of opioids within the medical community at large will likely not go away anytime soon. It will be incumbent on health care professionals to take actions that require walking a fine line to deal with the ever increasing challenges associated with aiming to keep opioids from those who may be abusing or diverting them, but also permitting those patients who need opioids for legitimate medical purposes the adequate access to opioids.

If you are a physician or pharmacy and would like more information on ESI’s new opioid program and what this program may mean for your prescribing or dispensing practices, contact Frier Levitt today.

Tagged with: , , , , , , , , , , ,
Share: