‘Extreme’ use of painkillers, doctor shopping, plague Medicare, says report

In Washington, D.C., a Medicare beneficiary filled prescriptions for 2,330 pills of oxycodone, hydromorphone and morphine in a single month last year — written by just one of the 42 health providers who prescribed the person such drugs.

In Illinois, a different Medicare enrollee received 73 prescriptions for opioid drugs from 11 prescribers and filled them at 20 different pharmacies. He sometimes filled prescriptions at multiple pharmacies on the same day.

These are among the examples cited in a sobering new report released last week by the inspector general of the U.S. Department of Health and Human Services. The IG found that heavy painkiller use and abuse remains a serious problem in Medicare’s prescription drug program, known as Part D, which serves more than 43 million seniors and disabled people. Among the findings:

• Of the one-third of Medicare beneficiaries in Part D (or roughly 14.4 million people) who filled at least one prescription for an opioid in 2016, some 3.6 million received the painkillers for at least six months.
• Consistent with data released last week by the Centers for Disease Control and Prevention, there were wide geographic differences in prescribing patterns. Alabama and Mississippi had the highest proportions of patients taking prescription painkillers — more than 45 percent each — while Hawaii and New York had the lowest — 22 percent or less.
• More than half a million beneficiaries received high doses of opioids for at least three months, meaning they took the equivalent of 12 tablets a day of 10-milligram Vicodin. The figure does not include patients who have cancer or those who are in hospice care, for whom such doses may be appropriate.
• Almost 70,000 beneficiaries received what the inspector general labeled as extreme amounts of the drugs — an average daily consumption for the year that was more than 2 1/2 times the level the CDC recommends avoiding. Such doses put patients at an increased risk of overdose death. Extreme prescribing could also indicate that a patient’s identity has been stolen, or that the patient is diverting medications for resale.
• Some 22,000 beneficiaries seem to be doctor shopping — obtaining large amounts of the drugs prescribed by four or more doctors and filled at four or more pharmacies. All states except for Missouri operate Prescription Drug Monitoring Program databases that allow doctors to check whether their patients have received drugs from other doctors before writing their own prescriptions.
• More than 400 doctors, nurse practitioners and physician assistants had questionable prescribing patterns for the beneficiaries most at risk (meaning those that took extreme doses of the drugs or showed signs of doctor shopping). One Missouri prescriber wrote an average of 31 opioid prescriptions each for 112 patients on Medicare. And four doctors in the same Texas practice ordered opioids for more than 56 beneficiaries who seemed to be doctor shopping. “The patterns of these 401 prescribers are far outside the norm and warrant further scrutiny,” the inspector general said.

To be sure, many seniors suffer from an array of painful conditions, and some opioids are seen as more harmful and addictive than others. Tramadol, often used to treat chronic osteoarthritis pain, was the most frequently prescribed opioid and carries a lower risk of addiction than other opioids, according to the Drug Enforcement Administration.

Moreover, last week’s report from CDC shows that painkiller use is ticking downward after years of explosive growth.

Still, officials in the inspector general’s office said more can and should be done to combat the problems they observed, even if the numbers are beginning to subside.

“I think what we’re saying here is this is still a lot of Medicare beneficiaries,” said Jodi Nudelman, regional inspector general for evaluation and inspections in the New York regional office, who supervised the report. “Regardless of if you are turning a corner, you’re still at these really high levels.”

The inspector general previously has called for Medicare to use its data to focus on doctors who are prescribing drugs in aberrant ways.

The inspector general’s numbers differ somewhat from an April report from the Centers for Medicare and Medicaid Services, which runs Medicare. The CMS report said that 29.6 percent of Part D enrollees used opioids in 2016, down from 31.9 percent in 2011. The inspector general pegged the 2016 figure at 33 percent but did not offer any historical comparisons. It was unclear why the two agencies came up with different figures.

In a statement, CMS said opioid abuse is a priority for the Trump administration. “We are working with patients, physicians, health insurance plans, and states to improve how opioids are prescribed by health care providers and used by patients, how opioid use disorder is diagnosed and managed, and how alternative approaches to pain management could be promoted,” it said.

Officials have known for years that opioid prescribing has been a problem in Medicare. ProPublica first highlighted the problem in 2013 when we published data on the drugs prescribed by every physician in the Part D program. Following that report, CMS put in place what it called an Overutilization Monitoring System, which tracked beneficiaries at the highest risk for overdoses or drug abuse. It asked the private insurance companies that run the drug program on its behalf, under contract, to review the cases and provide a response.

In a memo released in April, CMS said its monitoring system has been a success. From 2011 to 2016, it said, there was a 61 percent decrease in the number of beneficiaries who were labeled as “potential very high risk opioid overutilizers.” People were flagged that way if they were taking high doses of opioids for 90 consecutive days and received prescriptions from three or more doctors at three or more pharmacies. But the agency also said it would be implementing changes in January to better target those at highest risk of abuse.

Separately, in 2014, CMS told health providers they would have to register with the Medicare program in order to prescribe medications for beneficiaries. That way, the government could screen them and take action if their prescribing habits were deemed improper. Up to that point, doctors could prescribe drugs to Medicare patients even if they weren’t registered Medicare providers. Delay after delay has pushed back the requirement until 2019.

Dr. Cheryl Phillips, senior vice president for public policy and health services at LeadingAge, an association of nonprofit service providers for older adults, said managing pain in seniors is complex. Seniors are more likely to have conditions, such as orthopedic problems, cancer or degenerative joint disorders, which result in chronic pain. They sometimes don’t react well to non-prescription pain relievers, such as Tylenol, aspirin or nonsteroidal anti-inflammatory medicines. Health care providers like nursing homes are still evaluated, in part, on how well they manage pain, creating an incentive to turn to drugs.

“We have to challenge the notion that being pain free is a goal,” Phillips said. “It’s not that I want to see people suffering, but being pain free is perhaps a myth that not only society has been seduced with but physicians have as well.”

Phillips said she encourages physicians to explore nondrug alternatives, including meditation, mindfulness, moist heat and exercise.

This story was first published July 13, 2017, by ProPublica, a Pulitzer Prize-winning investigative newsroom. Sign up for their newsletter.