An increase in opioid drug addiction and overdose deaths during the past several years has prompted many state pharmacy boards, pharmacists and insurance companies to implement new policies that are designed to restrict access and stop abuse of prescription opioid medications. While these policies are important for tackling the national opioid epidemic, medical providers and patient advocacy organizations say they have created access problems for people who have cancer.
These patients depend on opioid medications to control pain, but they sometimes run into barriers put up by pharmacists and insurance companies who are trying to stem drug diversion and abuse.
A survey conducted last year by the American Cancer Society Cancer Action Network and the Patient Quality of Life Coalition found a significant number of patients with cancer had trouble getting their prescriptions filled because pharmacists and/or insurance companies questioned their legitimate need for the drugs.
Dr. Mihir Kamdar, director of the Cancer Pain Clinic at Massachusetts General Hospital in Boston and associate director of the hospital’s Division of Palliative Care, says several of his patients have faced these challenges.
“We definitely have seen patients have to go from pharmacy to pharmacy to try to find somebody who will fill (a prescription). I’ve had a couple of times where the pharmacist just refused to fill it,” Kamdar says, adding that he’s also run into these problems for his patients who don’t have cancer, but have chronic pain.
In one case, a patient who was discharged from the hospital after having surgery was unable to get an opioid pain medication filled. “The pharmacist just flat out refused to fill it,” Kamdar says. “And only after multiple phone calls would they give the patient enough until the next day, until we could write a new prescription to go somewhere else.”
The doctor also has run into more challenges with insurers. They now require more prior authorizations for opioid drug prescribing and demand extra authorization steps to prescribe higher quantities and doses of the medications. “We’ve had to do quantity overrides … where an insurance company won’t allow you to dispense the amount you want unless you state why,” Kamdar says.
Opioids are Crucial to Controlling Cancer Pain
Opioid pain drugs are particularly effective for controlling pain associated with cancer, especially advanced cancer. For people suffering pain from other kinds of diseases or conditions, the efficacy of opioids drops after the first couple of months of use. But for patients with cancer, it remains high and is unmatched by other kinds of pain drugs.
“They are really the mainstay for treatment for moderate to severe cancer pain,” Kamdar says.
Pharmacists also know the importance of opioids in treating cancer pain, so why are they putting up more barriers?
“Part of it is that pharmacists are being held to more accountability to really look for more of that diversion and abuse,” says John Marshall, director of Clinical Pharmacy Services at Massachusetts General Hospital.
Also, pharmacists working in retail settings often don’t have access to patients’ medical records. “So, they don’t maybe understand the nuances of why that patient needs (such a high dose), or why they’re on it chronically,” Marshall says. “There may be just a variety of other things that they need access to, to make a better decision on that.”
Marshall says it would help if retail pharmacists could access patients’ medical records. It would not be a violation of patient privacy laws because pharmacists are health care providers.
Pharmacists also worry they could potentially lose their license to practice if they are found to be negligent and dispensing opioids to a person who is misusing or diverting the drugs. “So, I think there are external pressures that pharmacists are continuing to feel at even a higher level now,” says Marshall.
What Can Patients Do?
If a pharmacist is refusing to fill a prescription, the patient “should page their clinician and ask them to speak to the pharmacist,” Kamdar says. “Most of the time, we’re able to negotiate that because we can explain what’s going on.”
Marshall agrees, and he advises patients to try to establish a relationship with a pharmacist who can get to know them and their particular situations and medication needs.
Kamdar also advises patients not to stay silent when they’re having a problem getting medications or with the amount of pain they’re experiencing. In fact, that’s a challenge he runs into often because, he says, patients with cancer tend to not complain.
“They’re oftentimes trying to be the ‘good patient,’” he says. “So, part of this is empowering them to be able to verbalize their challenges to their clinical care team — to their doctors, their oncologists, their pain specialists — so they’re aware that they’re having these issues.”
He also suggests that patients and family members get involved in patient-family advisory councils at health care organizations. Most large health care organizations have these groups where people can voice their concerns to medical and administrative leaders.
The Need for a Balanced Approach
Kamdar and Marshall agree there needs to be a balanced approach to monitoring and regulating access to opioid medications to make sure safeguards are in place, but also that people who legitimately need these drugs can get them.
This is necessary at the individual level and the public policy level. For example, Massachusetts General Hospital has lobbied with other organizations to ensure that state laws recently enacted wouldn’t create unintended consequences.
“The initial versions of these laws were very restrictive,” Kamdar says. “One of the things in the initial version of one bill was that they didn’t want to authorize anybody to have more than a seven-day supply of opioids — even cancer patients. We lobbied and wrote a letter to the state legislature and the governor’s commission to expand that to 30 days for patients who had cancer-related pain or were on palliative care in hospice.”
On the federal level, the American Cancer Society Cancer Action Network (ACS CAN) and the Patient Quality of Life Coalition, which ACS CAN operates, continue to push for legislation that keeps people who have cancer in mind, says Keysha Brooks-Coley, ACS CAN’s vice president of federal advocacy. She says the organizations acknowledge the need to address the opioid public health crisis.
“However, what we have asked for, and what we have wanted to be a leader in, is making sure the patient voice is included in the debate,” she says. “That’s really happened on the federal level in the past two years around addressing the opioid crisis and making sure that balanced policies were adopted.”
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