BCBSA Adopts Restrictions on Opioids

Family physicians say payers don't remove the barriers to non-pharmacological alternatives to chronic pain management such as physical therapy and home healthcare.  

A clinical guidance panel for the nation’s 36 Blue Cross Blue Shield companies has adopted a professional standard that opioids should not be prescribed as a first or second line of pain therapy in most clinical situations.

The standard was unanimously supported at the March meeting of the Blue Cross Blue Shield Association's National Council of Physicians and Pharmacist Executives, which includes physicians and pharmacists from Blue Cross and Blue Shield companies around the nation.

The standard is in line with guidelines from the Centers Disease Control and Prevention. BCBSA said its companies will promote alternatives that include more non-opioid prescription painkillers and over-the-counter pain medications.

"Due to the lack of evidence combined with significant potential for harm, we believe professional standards require that BCBS members are given alternative options to opioids in most clinical situations," said Trent Haywood, MD, chief medical officer for BCBSA.

"We will work with medical professionals to ensure BCBS members are routinely provided alternatives to opioids through a mutual decision made inside the doctor's office," Haywood said.

The standard adoption comes as the Centers for Disease Control and Prevention this week reports that drug overdoses in the United States are a growing problem for every demographic and region in the nation.

Drug overdoses killed 63,632 Americans in 2016. Nearly two-thirds of these deaths involved a prescription or illicit opioid. Overdose deaths increased in all categories of drugs examined for men and women, people ages 15 and older, all races and ethnicities, and across all levels of urbanization, CDC said.

More than 20% of BCBS commercially insured beneficiaries filled at least one opioid prescription in 2015, according to a BCBSA study. The report also showed beneficiaries with an opioid use disorder diagnosis spiked 493% over a seven-year study period.

Ryan Stanton, MD, an emergency physician in Lexington, KY, and a spokesman for the American College of Emergency Physicians, said the new standard from BCBSA will not have much of an impact in the emergency department.

"They’re jumping on to something we were already moving towards. Hospitals are re-evaluating the way we are addressing opioids," Stanton said.

"What BCBSA is saying, which our programs say a little better, is go with evidence-based medicine, which is what we didn't do with the opioid crisis," he said. "We were pushed in several different directions to give opioids for every pain complaint. What we are realizing now and what the evidence is showing is that they are not the best option in most cases."

Michael L. Munger, MD, a family physician in Overland Park, KS, and president of the American Academy of Family Physicians, said physicians understand that opioid misuse is a serious public health issue, but he bristled at the BCBS guidance.

"A blanket ban on the prescription of pain medication ignores the reality that each patient’s treatment must be individualize to his or her specific situation. Policies must recognize that pain management requires patient-centered, compassionate care as the foundation of treatment," Munger said.

"The AAFP opposes limiting patient access to any physician-prescribed pharmaceutical without cause, as well as any actions that limit physicians' ability to prescribe these products based on the physician’s medical specialty," he said.

Munger said BCBS and other public and private payers are pushing for a ban on drug therapies but do little to encourage non-pharmacologic therapies for chronic pain.

"The administrative burden and required pre-authorizations for prescribing non-pharmacologic therapies, such as physical therapy or home health, dissuades physicians from ordering such treatments," Munger said.

"Equally important, coverage plans require copayments and deductibles that add financial burden and disincentives to patients suffering chronic pain," he said.

Haywood said BCBS companies cover non-opioid pain treatment options, and medication-assisted treatments, and provide training for doctors and pharmacists, customized coaching services for those with chronic pain and support for families in addiction recovery. 

"Because Blue Cross and Blue Shield companies represent one in three Americans in diverse communities with diverse needs, we are taking a comprehensive approach to addressing the opioid epidemic through prevention, intervention and treatment," Haywood said.