New Jersey has passed a law limiting initial opioid prescriptions for acute pain to 5 days. However, it also requires insurers to cover up to 6 months of treatment for substance use disorders without preauthorization.
The law, which went into effect immediately upon being signed by Gov. Chris Christie (R-NJ) on February 15, is drawing mixed reactions.
New Jersey's 5-day limit is the strictest in the nation. Arizona, Connecticut, Delaware, Maine, Massachusetts, New York, Pennsylvania, Rhode Island, and Vermont have various limits — most around 7 days – for initial opioid prescriptions.
Maryland's governor has called for a 7-day limit on first prescriptions, and bills to restrict opioid prescriptions are pending in Georgia, Hawaii, Indiana, Kentucky, Montana, Oregon, and Washington, according to the Association of State and Territorial Health Officials.
The Medical Society of New Jersey, while supporting the new treatment requirements, opposed a 5-day prescribing limit, saying it was not evidence-based and that it would lead to many inconveniences for patients who legitimately need opioids.
Some addiction specialists were in favor of the limit, whereas others remained unconvinced. The mandated coverage for substance abuse treatment was almost universally praised. The law gives the treating provider — not the insurance company — governance over what is considered medically necessary treatment.
Michael Shore, MD, president of the New Jersey Society of Addiction Medicine, told Medscape Medical News that this shift was critically important. But Kelly Clark, MD, president of the American Society of Addiction Medicine (ASAM), said that because the law does not specify that a physician be the treating provider, some patients might receive sub-par care. "It's possible that a patient may never see or be evaluated by a physician at all during the course of many months of treatment for which coverage is mandated," Dr Clark told Medscape Medical News.
The New Jersey law flew through the legislature, having been introduced, voted on, and signed into law within a month. Gov. Christie and legislators who supported the law used an oft-cited statistic — promulgated by the National Institute on Drug Abuse, among others ― that 4 out of 5 heroin users started off with a prescription opioid.
As in many states, overdose rates have skyrocketed in New Jersey. For 2015, the state medical examiner's office reported 1587 overdose deaths, with 961 from heroin or morphine, 417 from fentanyl, 414 from cocaine, 302 from oxycodone, and 103 from methadone. That was up from a little more than 1200 overdose deaths — 596 from heroin or morphine ― in 2012.
New Jersey had a 16.4% increase in drug overdose deaths from 2014 to 2015, according to the CDC.
The New Jersey statute is a mash-up of the Centers for Disease Control and Prevention's (CDC's) March 2016 chronic pain opioid prescribing guidelines for primary care physicians and its own recommendations.
For acute pain, a prescriber can only issue an initial 5-day supply for the lowest possible immediate-release dose. Patients who need more have to make an in-person visit for a refill, which can be for up to 30 days. At the time of the issuance of the third prescription, the prescriber and patient must enter into a pain management agreement.
Patients in active treatment for cancer, those receiving hospice or palliative care, or those who reside in long-term care facilities are exempt from these limits.
Mishael Azam, chief operating officer of the Medical Society of New Jersey, said the law is misguided, because there is no evidence that prescribing limits can reduce heroin use.
Also, a return visit to get a new opioid prescription is not realistic for patients who have transportation problems, are too sick to come in, or cannot get an appointment in a busy practice, she said. In the wake of the CDC guidelines, "we've already seen patient backlash," Azam told Medscape Medical News. She noted that some physicians have stopped prescribing opioids and are refusing to see pain patients.
The new law will likely further reduce physicians' willingness to prescribe opioids, she said.
"While we're reducing stigma for addiction patients, we're increasing it directly on to pain patients," said Azam. Despite its objections, the Medical Society of New Jersey has "been telling our doctors to change their practice ASAP," she said.
Dr Shore, who has a psychiatric and addiction medicine practice in Cherry Hill, New Jersey, agreed that the 5-day limit was ill-advised.
"It's not workable," he said. Even though 80% of the people with acute pain would not likely need more than 3 to 5 days of medication, some people who have a severe injury or postoperative pain will need more, said Dr Shore.
"It's really an unfair burden, and I don't think it's going to solve the problem," he said. He predicts "there will be an outcry," from patients.
A Blow to Insurance Companies
Petros Levounis, MD, professor and chair of the Department of Psychiatry, Rutgers New Jersey Medical School, Newark, disagrees.
"The legislators seem to be looking at the problem the right way," Dr Levounis told Medscape Medical News. He said he was not sure what the right limit was, but that it is commendable that the law is "an effort to look at the root cause of the problem, rather than the effect."
His solution is to "limit the number of opioids, but allow the physician still to have access to them, perhaps with the signing of an informed consent" by the patient that acknowledges the risk for addiction, said Dr Levounis, who is a member of the American Psychiatric Association's Council on Addiction Psychiatry.
The New Jersey law strikes a blow against insurance companies by requring that the first 180 days of inpatient and outpatient treatment be provided "when determined medically necessary by the covered person's physician, psychologist or psychiatrist" without prior authorization or any other prospective utilization management.
The coverage mandate would only apply to 30% of New Jersey residents who are covered by a state-regulated health plan. But experts interviewed for this story said they expect the remainder of insurers — which are federally regulated — to follow along with the mandate.
The new law would also require the following:
Placement of the covered person within 24 hours, with exceptions if no in-network provider is available;
No prepayment of medical expenses greater than the co-pay, deductible, or co-insurance;
No concurrent or retrospective review or any other utilization management review of outpatients visits;
No retrospective or concurrent review of medical necessity during the first 28 days of inpatient stays, intensive outpatient, or partial hospitalization, and concurrent review no more than every 2 weeks after day 29.
"When a person who is in the throes of addiction, as you know, realizes he or she needs help, they should not be blocked at the treatment center doors with their life hanging in the balance because their insurance carrier requires a preevaluation that could take weeks to complete," said Gov. Christie after signing the bill. "Now, with this legislation, people seeking treatment cannot be denied access in their time of need," he added.
Dr Shore said it is critical that treating clinicians — whether psychiatrists or psychologists — are being given so much leeway in determining medical necessity.
Loss of Checks and Balances?
The ASAM has developed criteria for patient placement, but insurance companies do not always use them, and the physician often is aware of other factors that indicate that a higher level of care is needed. "The physician knows, but you're butting your head against a wall," Dr Shore said.
The shift away from the insurance company is "tremendously important," said Dr Levounis, noting that preauthorization for substance use disorder has been the norm. The patients are motivated, "but they get easily frustrated by a huge bureaucracy and a system that is not amenable to providing treatment when they need it the most."
Dr Clark said she was concerned that the pendulum might have swung too far and that removing insurers' oversight could lead to lower-quality care. "There may be a loss of some checks and balances," she said.
She also said that care needs to be individualized and that inpatient treatment for opioid addiction has been shown to be ineffective.
"If we're talking about improving access to treatment for the opioid epidemic, that means increasing access to medication-based treatment, not simply sending people away for months," said Dr Clark.
Christie, for one, said the law would remove barriers to medication-assisted therapy.
"Covered medication-assisted treatments must be provided without the imposition of a prior approval from a carrier. This is incredibly important, and we know that this medication-assisted treatment is the key for lots of folks to getting on the road to recovery and staying there," Christie said.
Dr Shore is a paid consultant for Indivior Pharmaceuticals and a consultant to the Medication-Assisted Treatment Program at the Malvern Institute. Dr Levounis has disclosed no relevant financial relationships.
Medscape Medical News © 2017
Cite this: New Jersey Passes Nation's Strictest Opioid Prescribing Law - Medscape - Mar 08, 2017.