Express Scripts to place new limits on opioid prescriptions, drawing criticism from AMA

Hydrocodone opioid pills
Express Scripts will roll out a program on Sept. 1 that will limit opioid prescriptions for first-time patients. (Getty/smartstock)

Express Scripts, the country’s largest pharmacy benefit manager (PBM), plans to roll out a new program nationwide that will limit the number and strength of opioid medications that doctors can prescribe to first-time users.

The program, which will begin on Sept. 1, is being put in place to help reverse the country’s opioid epidemic, according to the Associated Press. President Donald Trump last week said he was prepared to declare a national emergency to combat the deadly opioid crisis.

The move by Express Scripts was met with resistance by the American Medical Association, the largest U.S. organization that represents doctors. It said decisions about prescriptions and treatment plans should be made by doctors and patients, the AP reported.

The program will change the way insurance companies that use Express Scripts to control prescription costs will approve and cover the opioid drugs that doctors prescribe. A competing PBM, CVS Caremark, has a similar program that imposes a 10-day limit and limits dosages, according to the AP report.

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Under the Express Scripts program, patients receiving their first prescription for opioids will be limited to a 7-day supply, even if their doctor orders the painkilling drugs for additional days.

The program will also require short-acting drugs for first-time prescriptions, even though many doctors prescribe long-acting opioids, the AP reported. The program will also limit the dosage prescribed.

The company will monitor prescriptions to try to prevent patients from seeking opioids from different doctors and send a letter to new opioid patients warning about the dangers of misuse and addiction.

The program will not apply to patients in hospice or palliative care or cancer patients, the report said.

The rollout builds on a yearlong pilot program launched by Express Scripts in 2016 that's aimed at reducing early exposure to opioids and preventing progression to overuse and abuse.

In a pilot study of more than 100,000 members new to opioid therapy, the company saw a 38% reduction in hospitalizations and a 40% reduction in emergency room visits when compared to a control group during 6 months of follow-up.

The AMA does not support the program’s expansion.

"We want to be proactive in making sure the alternatives are available, versus a sort of blunt, one-size-fits-all-all approach regarding the number of prescriptions," Patrice Harris, M.D., who chairs the group’s opioids task force, told the AP. Doctors have already reduced opioid prescriptions by 17% and are directing patients to other forms of pain management, she said.

RELATED: Hospital Impact—PBMs are worsening the opioid epidemic

As the country tries to combat the opioid epidemic, both government and private payers are adopting policies aimed at regulating and reducing prescription opioid use.

Medicaid has implemented policies such as prescription drug monitoring programs, quantity limits on opioid dispensing, prior authorization requirements, preferred drug lists and patient review and restriction. In 2012, 15% of Medicaid enrollees had at least one prescription opioid claim, and the program paid more than $500 million for more than 34 million claims for opioid drugs.

Cigna also recently announced that it recorded a 12% decline in customers’ use of prescribed opioids in the last year, which it accomplished by leveraging its claims data to detect patterns of misuse and by working with doctors.