Idaho pain sufferers are forced by their insurers to use morphine

He wanted to provide tramadol to the sufferer.

According to the government categorization system established up to track drug hazards, the pain medicine is a “Schedule IV” substance, which implies it has a “low potential for misuse and low risk of dependency.”

The insurance company, however, demanded that the patient first take morphine. A “Schedule II” substance, which is two notches above tramadol on the addictive drug classification, has a “strong potential for misuse, with usage possibly leading to serious psychological or physical dependency.”

Three separate health insurance companies have notified Radnovich at least five times since late July that his patients must first take a medicine that government authorities think is more prone to misuse before they would pay the therapy he wants to offer them.

Radnovich is not a family physician. His patients usually see him as a last option. They’ve undergone a number of back surgery. They were involved in horrific vehicle accidents. They suffer from fibromyalgia or persistent pain that is not alleviated by physical treatment.

Patients with Regence BlueShield of Idaho insurance were rejected Radnovich’s option of a Butrans patch — a long-acting form of the opioid buprenorphine classified as “Schedule III,” with a “moderate to low risk for physical and psychological dependency” — in at least three instances.

Regence was ready to pay for a fentanyl patch or morphine pills instead of the patch.

That decision irritated Radnovich.

“There is no trustworthy evidence that one opioid is more effective or safer than another…” Regence made the announcement in an emailed statement. “All opioids are addictive and diversion-prone.”

When individuals do not utilize opioids as prescribed, they are all harmful. Fentanyl, another Schedule II drug, is very hazardous when taken recreationally or inadvertently.

Failure to follow the instructions

In the medical profession, “step treatment” refers to an insurer instructing a clinician that a patient must take one medicine before moving on to another.

Companies often force patients to take less costly medications — and “fail” to benefit from them — before moving on to more expensive or brand-name treatments. If the doctor and patient refuse to cooperate, they may urge the insurer to reconsider, or the patient can pay for the prescription out of pocket instead of receiving insurance coverage.

Step therapy is a method for insurance companies to save money for themselves and their subscribers.

Earlier this month, for example, a month’s supply of Butrans patches cost $360 to $650 at a nearby drugstore. A box of 90 morphine pills costs about $240.

However, the technique is contentious, and some patients are forced to squander time and money on therapies that do not work. Other states have enacted legislation prohibiting the practice. Last year, Radnovich urged that the Idaho Medical Association campaign for comparable legislation in Idaho.

Step therapy interferes with a doctor’s capacity to make choices based on a patient’s particular requirements, according to Stacey Worthy, who runs the Washington, D.C.-based advocacy organization Aimed Alliance. Pharmaceutical corporations contribute to the group’s funding.

“I don’t think the insurer should be interfering with the relationship, and there are other checks and balances in place to make sure these rogue prescribers are caught, losing their licenses, and going to jail,” Worthy said, referring to recent state-run prescription databases, medical board sanctions, and arrests. “The question here isn’t whether patients should take a less addictive prescription first, but who makes the choice.” When it comes to step treatment, it is the insurance that requires it, not the physician.”

In January, Regence will change its policy to eliminate the step-therapy requirement that patients first use low-cost morphine. Instead, Regence intends to concentrate on “appropriate dosages and durations for acute usage” as well as “proper patient selection, dosing, and monitoring for chronic opioid use,” according to the Statesman.

Opioid usage vs. opioid addiction

The insurers’ choices have some logic to them.

The Centers for Disease Control and Prevention published guidance last year discouraging physicians from prescribing opioids to individuals suffering from chronic pain. According to the study, primary care physicians should only prescribe the lowest feasible dosage in an immediate-release form for a limited period of time. According to the CDC, health care professionals issued 249 million opioid prescriptions in 2013, with many of those prescriptions not being utilized for medical reasons.

However, not all sufferers are the same, according to Radnovich and pain advocacy organizations. Those who wind up at Radnovich’s clinic have been in agony for years. Some people are unable to walk without medicine. Having to take Schedule II medicines may complicate their treatment; for example, you won’t be able to receive refills.

Radnovich checks his patients before beginning them on opioids and continues to monitor them using procedures such as urine testing while they are under his care, he added.

People with chronic pain, according to Worthy, may become addicted on opioids, which means they require the pills to function and live as normal a life as possible. Dependence is not the same as addiction or drug abuse.

The national opioid campaign hasn’t always acknowledged that difference. Making it more difficult for persons who misuse or sell opioids to get them has also made it more difficult for patients who have a valid medical need to obtain them.

The CDC “has been looking back at what they’ve done, and they’re seeing it’s harming folks who are in long-term [pain] treatment,” according to Jan Chambers, the National Fibromyalgia and Chronic Pain Association’s president.

However, beginning in January, the agency that governs Medicare and Medicaid will compel opioid prescriptions to meet the CDC’s recommendations, potentially leaving patients in the dark, according to Chambers.

Priorities are being questioned by the doctor.

Radnovich said that he is not inherently opposed to step therapy. What he wonders is whether insurers are taking the necessary initial measures, such as mandating Schedule II medicines in the midst of an opioid crisis.

“If we want to say the objective is, ‘We want to decrease the community’s exposure to opioids,’ that should be a priority,” he added. “We have insurance companies telling us they don’t want doctors to prescribe more than a specific amount of medications… yet they’ll say inconsistently, ‘We want you to utilize morphine before tramadol.'”

This insurance approach to opioids, according to Radnovich, who sees up to 100 people each week in Boise and Caldwell, is a new phenomenon. He sees it at least twice a month, and frequently with new patients. He doesn’t recall it occurring before last year, but he admits it might be related to his and his patients’ growing aversion to more abuse-prone medications.

According to ProPublica, Radnovich has received compensation from pain pharmaceutical manufacturers, including more than $7,000 in 2015 for promotional speaking, training, and teaching on goods containing Butrans. In 2011, he informed the Statesman that the costs, which are equivalent to those for expert witness evidence, offset the money he loses by being out of the office.

Radnovich said that he prefers to use a Schedule III patch for a variety of reasons. It provides medicine for a week. This prevents a patient from taking a drug that works for a few hours, then wears off precisely before the next tablet is due, creating a Pavlovian response to pain and medicines, he claims.

It’s also a suitable alternative for chronic pain patients with a “high abuse profile,” such as those who have previously battled with alcohol or narcotics.

One significant advantage, he claims, is that it does not induce euphoric highs.

“I don’t want to take the possibility that my patient would dislike a medicine, therefore I don’t want them to be exposed to it,” he said. “It boggles my mind that an insurance company would compel me to write morphine [prescriptions] instead of tramadol….” In what reality is that a reasonable reaction to what’s going on?”

Blue Cross of Idaho’s pharmacy director, Steve Olson, said his business had “very few” pre-approval hoops to jump through for narcotic or opioid prescriptions due to the dearth of one-size-fits-all treatments. He said that individuals are not required to “step-through” morphine before using tramadol.

“With the exception of fentanyl drugs, we leave prescription choices up to clinicians,” Olson said. “Because fentanyl is extremely addictive, we do ask doctors to give documentation of a cancer diagnosis for patients.”

Regence wants to raise the threshold for patients requiring pain medication as part of the January reforms, according to spokesperson Lou Riepl. The corporation will demand pre-approval for all opioids and impose quantity limitations for long-acting opioids.

This is due to the company’s recognition of “the seriousness of the opioid problem in our communities, and we are dedicated to minimizing opioid addiction while promoting responsible usage for patients who may benefit from opioid therapy,” according to Riepl.

According to, controlled substances

Schedule I: There are no presently recognised medicinal uses for this substance, and it has a significant potential for misuse. Examples include heroin, marijuana, and ecstasy.

Schedule II: High abuse potential, with usage possibly leading to serious psychological or physical dependency; hazardous. Methadone, oxycodone, fentanyl, and medications containing fewer than 15 mg of hydrocodone per dosage are examples.

Schedule III: There is a moderate to low risk of physical and psychological dependency. Ketamine and medications containing fewer than 90 milligrams of codeine per dosage, such as Tylenol with codeine, are examples.

Schedule IV:  Drugs have a minimal potential for misuse and a low danger of dependency. Soma and tramadol are two examples.

Schedule V:  Lower abuse risk than Schedule IV. Lyrica and cough medication containing fewer than 200 milligrams of codeine, such as Robitussin AC, are two examples.