By GREGORY W. MOORE & ALEXANDRA A. HALL
Forty-eight thousand Americans were lost to opioid overdoses in 2017. Michigan opioid-related deaths and overdoses rank 18th-highest in the nation. Over the last year, significant attention was dedicated toward combating this widespread issue on both a federal and state level.
Recently enacted Michigan opioid laws were executed with the intent to save lives and decrease misuse of controlled substances. In effect, the laws have imposed significant administrative hurdles and led to some confusion among prescribers, pharmacists, and patients.
The new laws impose substantial obstacles for prescribers prior to writing a prescription for opioids. Among such obstacles include the requirement that when a prescriber issues the first prescription for a controlled substance containing an opioid to a minor, he or she must discuss various risks of addiction and overdose with the minor and the minor’s parent or guardian and obtain the signature of the minor’s guardian on a form issued by the state. Certain exceptions to this general rule include treatment associated with a medical emergency or surgery, if compliance would be detrimental to the minor, or if consent of the minor’s guardian is not required for the treatment. To complicate it more, if the individual signing the form is authorized to consent but is not a parent or guardian, the prescriber may not prescribe more than a single 72-hour supply of a controlled substance containing an opioid. The laws also require that all prescribers register with the Michigan Automated Prescription System (MAPS) prior to prescribing or dispensing any controlled substance and obtain and review a MAPS report before prescribing or dispensing more than a three-day supply of any controlled substance. Perhaps the most confusion surrounds a seven-day supply limitation for providers treating a patient for acute pain, leading pharmacists to question whether to allow partial refills and whether the prescription was for acute or chronic pain.
The initial effect of Michigan’s recent changes are that providers are often deterred from prescribing opioids for fear of liability, which has made it difficult for individuals who need these medications to get them.
On October 24, 2018, President Trump signed a 660-page opioid bill which aims to help curb the crisis on several fronts. The legislation directs funding to federal agencies and states to increase treatment for addiction and places interventions such as increased training of law enforcement to intercept shipments. Notable progress in the realm of treatment includes increased Medicaid funding for addiction treatment and the removal of the Institute for Mental Disease (IMD) exclusion that prohibited federal Medicare dollars from going to inpatient treatment centers for substance use disorders with more than 16 beds. This allows states to provide access to residential treatment for Medicaid enrollees in need of substance abuse treatment who were previously treated with frequent visits to the Emergency Room. This is a change that has been long advocated by those who are battling a lack of funding and treatment options for addiction.
On a more molecular level, to assist states in the identification of high risk patients, the Office of Inspector General, U.S. Department of Health and Human Services, has issued a “toolkit” for use by State Medicaid Fraud Control Units, Private Health Plans and others to assist in analyzing prescription drug claims data. The release of this toolkit arose out of the OIG’s recent analysis of Medicare Part D data wherein it identified 71,000 beneficiaries which it described as individuals at serious risk of misuse or overdose of opioids. The toolkit provides steps to calculate a patient’s average daily morphine equivalent (MED) which converts opioids and strengths into a standard value. The CDC recommends that physicians consider a patient’s MED level when prescribing opioids and patients with chronic pain should avoid daily dosages at 90 mg MED or more. The toolkit includes a Programming Code along with instructions to use the Code and analyze the data output.1 It is anticipated that Medicare Part D plan sponsors, private health plans, and Medicaid Fraud Control Units will immediately begin to utilize this Code to analyze claims data and begin notifying providers in an effort to improve care coordination and case management, and alert providers to increased risk of overdose and possible diversion.
Despite recent efforts, all parties agree that significant work on both federal and state levels remains in order to accomplish the universal goals: save lives and decrease abuse.
1. A download of the SAS programming code can be found here: https://oig.hhs.gov/oei/reports/oei-02-17-00560.asp