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nearly 62,000 physicians, had signed a Cigna pledge to reduce opioid pre- scriptions and to treat opioid-use dis- order as a chronic condition. By sign- ing that pledge, practitioners say they will “support the CDC guidelines with us and prescribe opioids with caution,” Dr. Watson said. “What we’re trying to do is mini-


WSdO \]^ ^SWO ObZY]_\O] ^Y ^RO `O\c addictive drugs,” he said. Exclusions from Cigna’s new opioid policies include patients in hospice care and people with can- cer and sickle cell disease. The prior authorization for new long-acting opioids claims would “help ensure dose, duration, and intent of the pre- scription are clinically appropriate,” Cigna said. With regard to the limit for new short-acting opioid prescrip- tions, Dr. Watson says patients being treated “for something very minor — an ankle sprain, some acute back pain … shouldn’t require more than 15 days for that self-limiting condition.” Cigna is mindful of the albatross that new requirements can become for physician prescribers, Dr. Watson said,


“and I think it shows through the ex- ceptions that we’ve provided, [where] if someone has received medications in the last 120 days, there’s no require- ment for prior authorization.” “We’re very sensitive to that need and don’t want to place that admin- istrative burden on the physician,” he said. “It’s really at the point of deci- sionmaking for a first-time person asking whether or not a more power- ful medication is needed or a very long supply of a short-acting medicine is required. We know that both of those, because they’re highly addictive, we know they can lead to substance use disorders.”


PHYSICIAN CONCERNS


Prior authorization in general can be a roadblock for physicians in many cases. So, naturally, doctors have their reservations about adding more drugs to prior authorization lists. Dr. Hurley, the Texas Pain Society


TMA PART OF THE FIGHT


During the past two sessions of the Texas Legislature, TMA has thrown its support behind practical solutions to address opioid overdoses. In 2015, TMA supported successful legislation to expand access to the overdose-rescue drug naloxone. (See “A True Antidote,” October 2015 Texas Medicine, pages 41–47, or visit www.texmed.org/ TrueAntidote.) During this year’s legislative session, TMA fought lawmakers’ at-


tempts to require physicians to check the state’s prescription moni- toring program (PMP) before issuing a prescription for any controlled substance. TMA instead backed a technology-based solution to the opioid crisis, using the state’s PMP to identify potential instances of harmful prescribing, diversion, and doctor-shopping. (See “Unwel- come Diversions,” May 2017 Texas Medicine, pages 35–43, or visit www.texmed.org/UnwelcomeDiversions.) Ultimately, legislation passed that will implement those technologi- cal suggestions but that also will require prescribers to check the PMP before prescribing opioids — as well as three other drug classes ― beginning Sept. 1, 2019. TMA successfully fought for the 2019 delay to give stakeholders more time to study how to combat the opioid crisis. TMA’s Task Force on Behavioral Health also has been actively en- gaged in studying opioid abuse.


president, says he went through the prior authorization process for a Cig- na-insured patient in September and had to request preauthorization for a United patient not long before that. “They wanted to know if we had an opioid agreement. They wanted to know what the diagnosis was. They wanted to know current medications. They wanted to know other forms of treatment. It can be quite burdensome if I had to do that for everybody,” Dr. Hurley said. “Everyone is concerned with untimely deaths associated with opioid therapy, and we’re all trying to stop overdoses. But requiring authori- zations for short-acting or long-acting opioids is a burden to pain manage- ment clinics.”


He believes the burden “could be


astronomical” for large primary care practices. Dr. Hurley’s pain manage- ment operation at Coryell Memorial Healthcare System in Gatesville does


“a whole host of things” to mitigate the risk of opioid deaths, including monthly or quarterly drug screens, physical and psychological evalua- tions, and checking the prescription monitoring program (PMP) for all patients. “We are prepared for that because


we don’t take care of hypertension, and we don’t take care of diabetes. Our focus is on the pain symptoms and im- proved function,” he said. “But if you have a large primary care practice in which you’re taking care of every pa-


November 2017 TEXAS MEDICINE 39


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