Swamped by Medicaid appeals, state suspends painkiller policy

By Kyung M. Song
Seattle Times staff reporter

	DEAN RUTZ / THE SEATTLE TIMES Medicaid patient Dave Gallaher, a former Boeing worker, takes OxyContin for a degenerative spinal problem. He said he and his doctor endured a "two-week fiasco" with paperwork to get authorization to continue the drug instead of switching to a cheaper, state-preferred drug.
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Just weeks after Washington designated two of the cheapest forms of narcotics as "preferred" painkillers for low-income Medicaid patients, a flood of appeals from patients and physicians forced the state to temporarily suspend its refusal to pay for more expensive name-brand drugs without a medical exemption.

The moratorium, in force until at least next Thursday, means Medicaid patients using OxyContin, Fentanyl patch or other nonpreferred painkillers won't have to switch medications — at least for now.

The preferred drug list and the moratorium apply to the 500,000 state residents who have traditional fee-for-service Medicaid coverage. Cancer patients, who account for about 30 percent of prescriptions for narcotic painkillers, are given automatic exemption for those drugs.

Medicaid officials say the moratorium is not a sign they're backing away from the state's preferred drug list, which has been adopted in steps over the past two years.

Washington so far has named several dozen drugs as preferred choices for 13 varieties of ailments, including chronic pain, urinary incontinence, inflammation and high cholesterol.

	AP The state's Medicaid preferred drug list includes drugs such as morphine, which Medicaid deems just as effective as costlier, name-brand painkillers such as OxyContin, shown here.

The preferred drugs are deemed by Medicaid to be just as effective and to have side effects no worse than costlier alternatives.

Washington is in the process of adopting similar preferred drug lists for some of its state employees and for workers'-compensation patients.

Requiring fee-for-service patients to use cheaper drugs is central to the state's plan to curb its $500 million in annual spending for Medicaid prescription drugs.

The preferred list is especially important because federal Medicaid rules bar Washington from imposing copays on prescription drugs, which private health insurers use to encourage use of cheaper generics.

OxyContin has garnered headlines for the growing number of users who abuse it to get high or who have become dependent on it, most notably conservative talk-show host Rush Limbaugh.

However, cost, not concern about abuse, is the reason for excluding OxyContin from the state's list of preferred drugs. Washington's Medicaid program spent $14 million last fiscal year for OxyContin, which became available by prescription only in 1996.

Methadone is vastly cheaper than any other long-acting narcotic painkiller. It costs Medicaid 26 cents for a dose that is supposed to be as effective as a 60 mg dose of morphine, which costs Medicaid $2.36.

An equivalent dose of OxyContin costs $4.73.

Some patients and doctors fear Washington's preferred drug lists will limit their treatment options too severely. Though drugs may be considered equally effective, they can affect patients unequally, pain experts say.

Some drugs are shorter lasting and must be taken more frequently. Long-acting painkillers can deliver more-even pain relief.

Reaction was particularly strong after Washington designated morphine and methadone as the preferred long-acting painkillers Nov. 1.

Callers quickly swamped Medicaid's prior-authorization phone lines seeking waivers to stay on their current prescriptions.

In one week, the number of daily calls and faxes nearly tripled to 1,600.

Stuart DuPen, a physician who practices at Swedish Pain Center, was so alarmed by the state's choices that he took his concerns directly to the state Medicaid program's chief medical officer, Jeff Thompson. DuPen, who chairs the clinical-guidelines committee of the American Pain Society, said morphine and methadone simply do not give physicians enough options to treat acute pain.

Both opiates produce similar side effects, such as nausea, vomiting and respiratory depression, DuPen said, so a patient who can't tolerate one of the preferred painkillers probably can't tolerate the other, either.

Moreover, methadone is a particularly tricky drug to prescribe. Converting the dosage from another painkiller to methadone can be difficult, and overdose is always a danger, DuPen said.

"I have no trouble using methadone. But we need a broader list," DuPen said.

DuPen said when his office manager telephoned Medicaid to get waivers for his patients, she was on hold for 90 minutes. She never did get through.

The volume of calls for such waivers eventually forced the state to suspend for 30 days all prior-authorization requirements for painkillers Nov. 19.

Medicaid also suspended the preferred drug lists for ACE inhibitors, which are used for hypertension, and for Triptans, which are used for migraines, because the calls were handled by the same state employees.

Requests for exemptions from preferred drugs for four other medication groups, including antihistamines and acid-reflux drugs, are screened by a private company under contract with the state and remain in effect.

Thompson, Medicaid's chief medical officer, acknowledged that "there was a lot of people upset that they could not get their preferred opiate."

Thompson said that patients taking OxyContin, Duragesic, Kadian or other more expensive painkillers may believe the drugs work better, but "the evidence says that they are no more effective" than morphine or methadone.

Thompson stressed Medicaid ultimately defers to physicians.

If patients have unsuccessfully tried the preferred drugs or their doctors can justify needing a particular medication, the state will grant them an exemption, he said.

"They will get their drugs if they are medically necessary," Thompson said.

Dave Gallaher isn't reassured. Gallaher, 49, left his job as a Boeing Machinist in 1999 because of a degenerated spine.

He takes three OxyContin pills daily to tame his crippling pain, one more than the normal dose for the 12-hour drug.

Medicaid covers two daily pills; Gallaher pays for the third himself, at a cost of $275 a month. It's a huge expense for the Seattle man who lives on $687 a month in disability payments.

Gallaher said he and his doctor endured a "two-week fiasco" with paperwork to get authorization that would allow him to continue taking OxyContin.

Gallaher prefers OxyContin after his experience with another narcotic painkiller, Percocet. On Percocet, his pain worsened to the point where he had to pop one or two pills every four to six hours. OxyContin, on the other hand, is designed to last up to 12 hours.

Even with that, Gallaher was up to four OxyContin pills a day until lack of money and fear of building tolerance prompted him to lower it to three a day.

With a long-acting pill, "pain doesn't have a chance to rear its ugly head," said Gallaher, who uses a cane and a walker and who may eventually be unable to walk.

Gallaher remains leery of switching to morphine or methadone even though it would drastically cut his out-of-pocket drug costs.

He said he trusts his doctor, who wants him to remain on OxyContin because "if it ain't broken, don't fix it."

"You open up a whole can of worms when you start messing with people's prescriptions," Gallaher said.

Kyung Song: 206-464-2423 or ksong@seattletimes.com

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