'Only thing they’ll pay for is morphine ... ': Opioid alternatives routinely denied by insurers

For nearly two decades, Jim Lankford has lived with unrelenting pain.

It began with a fall at work that left him with an injury to his spine.

That led to a diagnosis of degenerative joint disease, broken vertebrae and dozens of surgeries.

The constant agony makes it tough for him to do any of his favorite pastimes, keep house and even sleep.

Although he’s taking painkillers, his doctor wants to prescribe treatments that he says are safer.

More:Opioids causing more in South Carolina to die prematurely

But the 63-year-old’s insurance plan won’t cover them.

“The only thing they’ll pay for is morphine ... or fentanyl or methadone,” he told The Greenville News. “I wish something could be done.”

Dr. Eric Loudermilk, an anesthesiologist and medical director of the Piedmont Comprehensive Pain Management Group in Greenville and Anderson, said Lankford isn’t alone.

There are alternatives that are less likely to result in accidental overdose or dependence, he said. But insurers don’t cover them.

More:Opioid crisis not letting up in Greenville County

“They want us to use morphine, fentanyl, methadone,” he said. “But fentanyl is one of the medicines you read about in the paper every day. Why would I want to use that when we’ve got these drugs out there that are available and they can make such a huge difference in the opioid epidemic?

“It’s very frustrating.”

Opioid numbers tell frightening story

The nation’s opioid crisis has become a staple of the headlines.

States are suing drug companies over opioids, and Congress is holding hearings about their misuse.

That’s because about 91 Americans die every day from an overdose of opioids, which include illegal drugs such as heroin and narcotic painkillers like oxycodone and fentanyl, according to the U.S. Centers for Disease Control and Prevention.

More than 33,000 died in 2015 alone.

More:Greenville County hires attorney for possible lawsuit against opioid manufacturers

And about 2 million people were addicted to prescription opioids that year.

Statewide, 5 million prescriptions are filled for opioids each year, and 1 in 4 people who takes them struggles with addiction, according to the state Department of Alcohol and Other Drug Abuse Services.

And 4 in 5 heroin users started with a prescription painkiller, the agency says.

In South Carolina, there were 616 fatal opioid overdoses in 2016 — 53 of them in Greenville County and 20 in Anderson County, according to DAODAS.

More:Born addicted: Greenville hospital pioneers new way to treat babies in withdrawal

Another 1,666 people around the state wound up in the ER and 13,083 went into rehab for opioid dependence.

“It is a real issue,” said Sara Goldsby, director of DAODAS. “I would hope our insurance companies would fairly reimburse for therapies and treatments that are alternatives to opioids.”

Less addictive options denied

Clad in blue scrubs and a surgical cap, Loudermilk, who is between medical procedures, points to an overflowing manila folder on his office desk one recent spring day.

“Here’s a stack of denials from just the last six weeks,” he said.

Sheet after sheet shows a denial for atypical opioids like buprenorphine, tapentadol and tramadol — a class of drugs Loudermilk said is less likely to result in overdose or addiction.

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Almost every time he or his partners write a prescription for one of these drugs, it’s denied for not being part of the insurer’s formulary, or list of drugs that are covered, he said.

Instead, he’s instructed to first use drugs in their formularies, like the conventional opioids morphine, Oxycontin, fentanyl, Percocet and dilaudid.

But Loudermilk said when patients stop taking older opioids like Oxycontin, they experience severe withdrawal, which doesn't happen with the atypicals.

“Patients want to get off it. But when they try, the withdrawal is terrible," he said. "So it’s hard to quit.”

More:What the GCSO plans to do to raise awareness of opioid addiction in Greenville

Loudermilk said his practice — which includes four physicians and five nurse practitioners — also gets pushback when trying to prescribe other drugs called abuse-deterrent opioids, such as Embeda, Xtampza and Morphabond, which can’t be crushed or otherwise altered to be injected or smoked.

“No one will say they cost more. But logic says it’s a cost issue,” he said. “The cheapest medicines are fentanyl, morphine and oxycodone. And we are being pushed to write those medicines.”

The high cost of nondrug therapies

It’s a problem for pain doctors and their patients around the country, said Dr. Steven Stanos, immediate past president of the American Academy of Pain Medicine.

Stanos runs a multidisciplinary pain clinic for a health system that offers traditional care as well as alternatives like acupuncture, physical therapy and psychology services, which are included in federal treatment guidelines.

“In situations involving the use of nonopioid therapies, insurers have been very slow to adjust in how they pay for treatments,” he said. “Nonopioid treatments ... are many times not covered or not covered consistently. Care is not being provided that should be.”

More:Pain patients caught in the opioid epidemic

Insurance won’t cover a psychologist to help a patient cope with chronic pain, for example, or if they do, the reimbursement is so low it’s challenging for hospitals to support that type of treatment, he said.

In addition, Stanos said, patients often must pay multiple copays for one visit because they’re there for more than one therapy.

“It can cost them hundreds of dollars a day just to participate,” he said, “and there are some who can’t afford to be in the program.”

There’s still no parity when it comes to paying for addiction treatment for chronic pain patients as well, he said.

More:Greenville's opioid problem brought to forefront at public hearing

“Even medications being recommended to treat addiction, it’s difficult to get them approved across the board,” he said.

Dr. Michael Grier, Loudermilk's partner, said there's no doubt that some people are taking too many medications and getting into trouble.

"But for the ones who really need it," he said, "they’re the babies being thrown out with the bath water.”

Insurers question alternatives' effectiveness

Cathryn Donaldson, spokeswoman for America’s Health Insurance Plans, the trade group for health insurers, said insurance companies work with health care professionals to provide the safest, most effective, evidence-based approaches while considering opioid abuse in ways that include more cautious prescribing and careful patient monitoring.

She said in a statement that there is limited evidence that abuse-deterrent opioids are effective, and no convincing evidence that they discourage opioid abuse or result in lower rates of illegal use. Those drugs are also substantially more expensive than their counterparts, she said, which increases health care costs for everyone.

More:Drug overdose deaths spike; 55-64-year-olds most affected

But Loudermilk said that while the upfront costs are higher, the long-term costs of addiction, dependence and rehab are far greater.

Dr. Matthew Bartels, chief medical officer for BlueCross BlueShield of South Carolina — the state’s largest insurer — said in a statement that the company evaluates appropriate pain management while working with health care providers to use evidence-based therapies with demonstrated success.

“Types of pain determine the first line of recommendations for pain management,” he said, “and there are numerous covered options available.”

He agreed the effectiveness of abuse-deterrent drugs is still being evaluated, and said there is "scant evidence" of their ability to reduce opioid abuse.

“As a result, at this time none of these drugs are on our formulary," he said. "Moreover, there is some concern that use of these drugs may cause unintended consequences, such as migration to heroin.”

Abuse-deterrent drugs won’t be a panacea for the opioid epidemic, Stanos said, but doctors feel more comfortable prescribing them.

“We feel it’s within best practices to try in any way with prescriptions we write to decrease the risk,” he said. “You want to do what’s best and safest for your patient.”

Stanos said some studies show a benefit to abuse-deterrent drugs, but it will be years before there is enough evidence — because they are so rarely covered by insurance, post-marketing research is difficult.

“It’s not like there’s no evidence,” he said. “But if you don’t increase access to a medicine, it’s hard to show the impact of that medicine.”

BlueCross covers buprenorphine and naltrexone for patients being weaned off opioids, and without the need for prior authorization, Bartels said.

“All health plans are grappling with the magnitude of properly addressing the issue of opioid use disorder,” he said, “and it is fair to say this is a subject many people within BlueCross are focused on every day.”

Targeting pain with the right medications

Donaldson added that atypicals like buprenorphine and tapentadol are still types of opioids and aren't necessarily safer, and also carry “a high risk of addiction and abuse.”

But Loudermilk said the drugs are safer. One of his patients tried to overdose on a bottle of tapentadol and survived, he said.

“If that had been morphine or fentanyl or oxycodone, she would have died,” he said. 

Loudermilk also argued that the drugs have been approved by the FDA as effective. Plus, he said, they are easier to stop.

The newer drugs also are better at controlling nerve pain, he said, adding that one reason patients need ever-increasing doses of traditional opioids is that they aren’t as good at relieving that kind of pain.

Donaldson said health plans work to ensure therapies are effective by evaluating research and using evidence-based guidelines, along with exploring and improving access to effective nondrug treatments, she said.

“Therapies like exercise, mind-body interventions, psychological interventions, massage and acupuncture can be an effective first line of treatment for many before moving on to pharmaceuticals when necessary,” she said. “In fact, it’s interesting to note that recent research shows that nonopioid medications ... can provide just as much relief as opioids.”

Still, while coverage of such treatments depends on the insurer and the health plan selected, they are unlikely to provide a solution to the opioid epidemic, she said.

Bartels said that while physical therapy, spinal stimulation and other treatments may be recommended, each case is unique and insurance benefits vary depending on employer coverage.

Appeals process time-consuming

Loudermilk said coverage for those therapies is frequently denied as well.

While patients can always appeal denials, according to Donaldson, Loudermilk said his office staff spends a great deal of time on that.

“Sometimes we get some short-term approval,” he said. “But it’s a battle.”

When they are authorized, he said, patients can find their copays are as much as $600.

“In our clinic, the number of prior authorizations and phone calls even to get those medications approved has expanded significantly,” Stanos said.

"So the extra time your staff needs on the phone and the physician uses filling out paperwork has increased exponentially,” he added. 

And it’s not only private insurance, Loudermilk said. Medicare and Medicaid insurers also routinely deny the safer treatments, he said.

"They won’t cover physical therapy, back support, TENS units," he said. "Only opioids. The dangerous ones.”

According to a statement from the Centers for Medicare and Medicaid Services, the agency is working with beneficiaries, states, providers and private insurers to combat the opioid crisis.

“As a payer, Medicare plays an important part in this effort by working to make sure providers are providing the right services to the right patients at the right time,” the statement said. “This includes combating harmful opioid overprescribing while not detracting from the necessary pain management care beneficiaries need.”

While most beneficiaries use opioids appropriately, and clinicians prescribe them appropriately, overutilization is a challenge for the Medicare Part D program, which covers prescription drugs, the statement said.

Agencies say they're combating problem

All Medicare formularies are subject to review and approval by CMS, according to the statement, and evaluated to ensure they conform with best practices, contain widely accepted drugs, and include several opioid alternatives for beneficiaries, who also have the right to request an exception for a drug not on the formulary.

Insurers also must have procedures in place so enrollees have access to drugs not on their formularies, including opioid alternatives, it said.

CMS also requires insurers to have compliance measures to detect, correct, and prevent fraud, waste, and abuse, the statement said, while helping insurers identify people potentially at risk for opioid abuse.

The state Department of Health and Human Services, which runs the Medicaid program, issued a statement saying that under Gov. Henry McMaster’s leadership, DHHS, along with public and private partners, is working to combat the opioid epidemic.

“As part of the department’s ongoing mission of providing high-quality, cost effective care,” it read, “it has issued guidelines to limit unnecessary or excessive opioid prescriptions, ensure providers and organizations are engaging in appropriate treatment options and provide our members access to reasonable and clinically appropriate alternatives to opioids.”

Loudermilk has been operating his practice for 21 years. Providers there see more than 200 patients every day, performing nerve blocks, administering steroid injections and implanting surgical devices to reduce pain, in addition to prescribing medications.

Most of the patients were inherited from other practices whose doctors were no longer willing to prescribe opioids for fear of being investigated and shut down by authorities, he said.

“It concerns us, too,” Loudermilk said, “because we have to prescribe more as a result.”

Doctors face tough choices

Most of the patients are in chronic pain, Loudermilk said, and most are on multiple medications, some for months to years.

They need a special approach to fine-tune their treatment so it can be as effective as possible while producing the fewest side effects and drug-drug interactions, he said.

By adding an anti-inflammatory, a muscle relaxant or nerve drug, for example, the number or dosage of opioids can be reduced, he said.

Some patients are able to get off medications entirely, he said. Some need everything in the tool kit — medications, interventions, surgery — to control the pain.

Some also suffer from anxiety and depression, which goes hand in hand with chronic pain, and needs to be treated as well, he said. 

“They’ve lost their job. And maybe their marriage or home,” he said. “If you don’t treat the depression, you won’t have any success treating the pain. Then you have a patient who commits suicide because life gets too difficult.”

Grier said every patient is different and needs to be managed for pain as an individual. But policies in place today are more of a one-size-fits-all approach, denying treatments or limiting them to a certain number of days, he said.

It’s hard to hear that physicians have to prescribe opioids first, Goldsby said.

Short-term costs vs. long-term savings

“There is a lot of evidence to suggest that in some cases these alternatives are safer and more effective,” she said. “We need a little bit of investment on the front end to prevent all the negative consequences that come with dependence and addiction.”

Loudermilk said it makes sense in the midst of an opioid epidemic to use more of the alternatives when possible.

“We have so many more options now than there were 20 years ago. So many more weapons to fight pain,” he said. "But we’re not allowed to use them. That would really help reduce this opioid epidemic.”

Goldsby said she realizes health care costs are high, but adds there should be a national push for coverage of alternatives.

“Physical therapy will always be more costly than a narcotics prescription,” she said. “But we’re all here with a sense of urgency every day seeing all these negative consequences. We can’t get too comfortable living in this crisis.”

Stanos allows that it’s a complex issue. But, he said, the expense of nonopioid treatments is far outweighed by patients’ lives or the adverse affects their opioid misuse might have on the people around them.

“We want to balance appropriate treatment for patients at the same time as we are limiting misuse or abuse,” he said.

“It’s unfortunate because we’re in the middle of what they describe as an opioid epidemic," he added, "and if we’re going to transform health care, all the stakeholders — payers, physician groups, regulators — have to be looking out for patient safety. We’re trying to do the right thing. There needs to be support across the board.”

A daily battle

Lankford’s battle with pain began in 1999.

A maintenance worker at a manufacturing plant, the Central man fell on the job, causing damage to his discs that required medication, then steroid injections and finally surgery.

“That’s when I learned I had degenerative joint disease, and from there my body just started to deteriorate,” he said.

One thing after another happened after that, including several arthroscopic knee surgeries, an injury that required his neck to be fused, and knee replacements. He wound up on disability.

Trout fishing, deer hunting and golf used to be among his favorite activities. But he can’t do any of those now.

Planting azaleas and mulching the flower beds is out of the question too. As is mowing the lawn and other daily chores.

The pain, he said, affects everything.

Over time, Loudermilk tried prescribing several opioid alternatives for Lankford, but none was covered until Embeda, the abuse-deterrent opioid.

While it helped the pain, the cost is a problem. At first, he was paying $47 for the drug. But in March, he hit what’s called the donut hole — a gap in Medicare drug coverage until he’s paid $5,000 out of pocket.

Now Lankford, who’s on a fixed income, pays $441 a month for the same drug.

If he had his way, he said, he wouldn’t be on any opioids.

“Drugs that would cost me less, he’s not comfortable prescribing and I can understand why,” he said of Loudermilk. “You see about that fentanyl, lots of people are dying from it.”

But he can’t live without medication.

“While we were trying to find (a medication), I was going through all this pain from month to month,” he said.

“If I didn’t have Embeda," he added, "I’d want to cut my foot off if I thought it would help."