GREENFIELD — On an icy night in 2008, George Busold of Greenfield, then a volunteer firefighter in Gretna, Va., received a call to respond to a head-on two-car crash.
One of the cars had flipped into a ditch, he said, and caught fire. The scene was halfway between his house and the station, so he went directly there and was first on the scene. Grabbing a 20-pound fire extinguisher, he hopped the guard rail and started down the embankment.
Then, the ground gave way.
Busold fell and landed on a big rock, herniating a disc in his spine. He didn’t realize he’d been hurt at first and was still able to help extinguish the fire, he said, but collapsed in pain soon after.
He tried to continue working with his injury, but the pain became too much.
Now, 8 years later, the cumulative effects of that injury and others Busold has suffered throughout his life have left him constantly in pain.
Like many other Americans whom the Centers for Disease Control and Prevention say received one or more of the 249 million opioid painkiller prescriptions written in 2013 alone, Busold became reliant on a galaxy of pills and other pharmaceuticals, including morphine and oxycodone, to dull the pain and allow him to function each day.
But those same drugs are widely recognized as one of the root causes of a national addiction crisis and overdose epidemic, and new federal and state regulations aimed at curbing overprescription and stopping powerful opioids from being abused or sold on the street have people like Busold and some medical professionals worried.
In 2014, the Massachusetts Department of Public Health estimated 1,174 people died from overdoses related to opioid drug use — the fourth consecutive year such deaths saw a marked increase.
Nationwide, more than 25,000 people died of unintentional overdoses in 2014, according to the National Center for Health Statistics.
As part of its efforts to stem the tide, the CDC recently released new guidelines that recommend trying less-powerful painkillers or non-pharmaceutical methods of pain management, like Yoga or physical therapy, before resorting to opioids, and prescribing far fewer of them.
In March, the state’s MassHealth program took a more direct approach, setting new limits on opioid prescription by halving the maximum amount of daily morphine equivalents a patient can be given from 240 millgrams down to 120 milligrams.
DPH spokeswoman Michelle Hillman told The Recorder that health care providers will be able to override the limit if necessary with the department’s approval.
Neither the state limits nor the federal guidelines apply to cancer patients or those who have recently had surgery. MassHealth, the state’s Medicaid program for the poor and disabled, in March defended its decision, saying it was designed to strike a balance between access to pain medication and prevention of abuse.
Private insurers have also taken measures to reduce opioid overprescription. In 2012, Blue Cross Blue Shield of Massachusetts introduced new rules that require prior authorization for all new short-acting opioids prescriptions for more than 30 days worth of pills within a 60-day period, and for all new long-acting opioid prescriptions, according to a company fact sheet. They also limit prescriptions for acetaminophen/opioid combinations to less than 4 grams per day.
Tom Kowalski, the company’s clinical pharmacy director, said the measures were designed to make sure patients had conversations with their doctors about the risks associated with opioid use before starting them.
“The premise was that we would limit the pills going out, while not creating a barrier and creating ways to get access if (the patient) has more long-term conditions,” he said.
Those rules will soon change, said Kathleen Makela, a company spokeswoman, to reflect new state legislation passed this winter that has placed more restrictions and regulations on opioid prescribing, including mandating use of a prescription monitoring system by doctors to track patients who may be seeking drugs from multiple providers, legalizing partial fills at the pharmacy and limiting the size of first-time opioid prescriptions.
Kowalski said the company is also currently reviewing its coverage plans to see how access to alternative pain treatment methods, like physical therapy, acupuncture or over-the-counter medication, could be made easier.
While the new guidelines and restrictions were being formulated, many doctors and medical professional groups cautioned against placing firm restrictions on medical practice like the MassHealth limits.
“There have been a number of expert opinions that have talked about increasing patient dosage slowly and carefully, but with minimal upper limits as long as they’re not getting into addictive behavior and there’s evidence of beneficial effects.” said Dr. Dennis Dimitri, the president of the Massachusetts Medical Society.
At the same time, Dimitri said, research has shown that prescribing above a certain level of milligrams of morphine equivalents per day provides less benefit and greatly increases the risk of accidental overdose. Exactly where that point lies, he said, is not clear.
While he considers efforts to rein in overprescription as one essential tool among many in fighting the opioid crisis, Dimitri said any restriction like the MassHealth limits needs to be accompanied by exceptions to give doctors time to wean patients down from high doses.
“It’s not only difficult, but it’s dangerous,” he said. “You cannot expect a patient to go down from 340 or 240 milligrams per day to 120 overnight; it’s an impossible task and it’s not safe.”
Dr. Ruth Potee, a local physician specializing in addiction and who treats Busold, believes the push to limit prescriptions has too broad a focus, to the point of harming the “vast majority of patients (on opioids) who get benefits from them.”
Potee is also active with the regional Opioid Task Force. Her husband, Dr. Stephen Martin, a family care physician at Barre Family Health Center, shares her sentiment.
Martin described one of his chronic pain patients who was unable to get his prescription filled after the March 7 deadline because it was over the 120 mg threshold.
“We’re talking about a gentleman who was doing exceedingly well — taking care of his kids, getting to appointments — and on an arbitrary date, at an arbitrary level, he was told ‘No.’ Now he can barely get out of bed,” he said.
Martin said he and his patient have been through three sets of documentation trying to rectify the situation with the state, and since there’s no way to track the progress electronically in real time, he said it’s a cumbersome and challenging process for busy doctors to pursue, and the results are time-sensitive for the patients.
The form requires the doctor to detail a patient’s medical history, covering a range of factors such as doctor’s notes, side effects of medication they’ve been on, any history of substance abuse, or adverse reactions to drugs, Martin said.
“When patients aren’t able to get these medications, it affects how they function; they get sick. It’s challenging to reproduce someone’s entire medical history on paper, but it’s a natural consequence of what they set up — they knew it was going to be complicated,” Martin said.
Figures provided to The Recorder by MassHealth show a total of 1,242 prior authorization requests have been submitted since the new limits went into effect, and about 75 percent of them have been approved. Of those requests, about 38 percent of them were for methadone.
“All prior authorizations are issued a decision within 24 hours of submission. The vast majority of these are actually completed within four hours,” the spokesperson said. “At times, a prior authorization request may be denied because all required documentation was not submitted. Additional documentation is then requested, which may result in some additional back and forth with the prescriber before an approval is granted.”
Martin said his patient was finally able gain approval on April 22 — nearly two months later — but even then ran into confusion at the pharmacy and had to have a new prescription for a slight lower — and less helpful — dose written.
“Maybe we’re just going through a rough patch, but we can’t keep doing this,” Martin said.
Martin said the threshold number itself is a bit arbitrary, too, noting that different factors such as a person’s weight and the tolerance they’ve built over the length of time they’ve been on opioids factor into determining the proper dosage that they need. That could be higher or lower than 120 mg, depending on the patient.
“If we can use a lower dose and get the same impact on function, then let’s do that. That’s good medical practice,” he said. “But let’s not do it under the crowbar of a regulation that just cuts people off at the knees.”
Busold is one of those people, Potee said.
Busold’s health problems started while serving in the U.S. Air Force in the 1970s. There, he said, he suffered tears to both of his rotator cuffs and experimental surgery failed to fully fix the damage. Torn ligaments in one knee eventually morphed into arthritis, and he has bone spurs in both. He suffers from non-diabetic neuropathy and arthritis in both of his feet, which he attributes to wearing steel-toed boots for most of his life, and multiple herniated discs in his back from the firefighting injury.
“Basically, arthritis in every joint in my body,” he said. Doctors have told him surgery to fix the injuries would be too risky compared to the possible benefit, he said, so all he can do is find ways to manage the pain. He can’t sleep in a bed, he said, so he spends his nights in a recliner.
Busold said he stopped going to the federal Department of Veterans Affairs — which had him on 90 milligrams of extended-release morphine pills three times per day and 10 milligrams of oxycodone four times a day — when his doctors tried to switch him off opioids to just Tylenol amid federal opioid limitation efforts. He said he applied for federal Medicare benefits and supplemental care through the American Association of Retired Persons in 2014, then sought out treatment at Valley Medical Group instead, where he was referred to Potee.
“It only took her six months to get me off of the morphine and the oxycodone,” he said. “She just weaned me off of them until now I get 20 milligrams of methadone three times a day and 5 milligrams of Percocet four times a day. And that doesn’t do anything.”
He said he supplements that with Tylenol and Advil to get any sort of relief.
“They’re trying to stop all these suicides or overdoses from illegal street drug use, I don’t deny that at all, but they’re taking it out on us, on the people who really need their medications through a legitimate source, monitored by a doctor,” Busold said. “I don’t like taking them to begin with. But they help. They give me somewhat of a normal life.”
Busold said he thinks decisions on how much pain medication patients, such as himself, should be prescribed should be left up to doctors trained in pain management.
“Let them make the decisions. Bureaucrats behind desks shouldn’t have a say in this,” Busold said. “Don’t make the honest, good citizens suffer. I pray to God to take me at times, the pain is so bad.”
Prior authorization requirements for MassHealth can be found at: tinyurl.com/zwenequ
You can reach Tom Relihan at:
trelihan@recorder.com
or 413-772-0261, ext. 264
On Twitter: @RecorderTom