Shut the back door to America's opioid epidemic

Shut the back door to America's opioid epidemic
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Opioid addiction is the greatest public health crisis we’ve faced in a generation. In 2015 alone, nearly 35,000 Americans died from prescription opioid overdoses. As a former U.S. Senator and attorney general for New Hampshire, I’ve witnessed first-hand the devastating impact of opioid addiction in our communities.

At pharmacies, opioid prescriptions are purchased one of two ways, using health insurance or with cash. Several initiatives by Pharmacy Benefit Managers (PBMs), the middlemen who administer pharmacy benefits for health insurance plans, have limited the supply of opioids that can be purchased by using health insurance.


These efforts include limiting to seven days the supply of opioids dispensed for certain acute prescriptions for patients who are new to therapy and limiting the daily dosage of opioids dispensed based on the strength of the opioid. While helpful, these steps are insufficient and leave a back door wide open for opioid abuse and so-called pill mills by providing little or no limits on cash purchases.

This is how the back door works. People pay cash for prescriptions because they lack insurance coverage or because they want to circumvent health insurance controls.  Cash prices for prescription drugs are set at artificially high markups, often as much as ten times more than the prices paid for the same drugs by health insurance plans.

To gain modest discounts to inflated cash prices, cash purchasers turn to prescription coupons known as “cash discount cards.” Even as PBMs limit access to opioids for patients using insurance, they issue cash discount cards that make opioid purchases easier to buy and more profitable for them. Prescription cash discount cards are heavily promoted in doctors’ waiting rooms, on television and on the Internet.

PBM cash discount cards are anonymous. With a cash discount card, it’s much easier to fill an opioid prescription at a pharmacy with no ID check, no drug history-check and with no health plan access limits. PBMs that issue cash discount cards do not monitor purchase behavior nor do they alert pharmacists or health insurance plans when cash discount cards are misused.

Predictably, PBM initiatives to control access to opioids purchased with health insurance may actually increase PBM profits. During my time as a senior advisor to Blink Health, a technology company focused on making prescriptions more affordable, I’ve learned that PBM profits are much higher for prescriptions paid for with cash discount cards than for prescriptions paid for with health insurance.

PBMs have led regulators and the public to believe they are fully invested in solving the opioid addiction crisis. Following the money tells a different story. By shifting opioid purchases to the cash pay back door, PBMs can increase their profits from our nation’s addiction epidemic.

I applaud the Senate Health, Education, Labor and Pensions Committee for its work on the Opioid Crisis Response Act of 2018 and the states’ attorneys general for their tireless efforts to stem this crisis.

Congress and the states should shine a light on the cash discount card back door by holding hearings with the largest PBMs that issue these cards for opioid sales, such as CVS/Caremark, Medimpact, Express Scripts, and Optum. PBMs issue cash discount cards 24x7 on the Internet and also in doctors' offices. For example, you could look at www.insiderx.com operated by Express Scripts or www.wellrx.com operated by MedImpact.

The American people are entitled to know how much the PBMs and national chain pharmacies profit from selling opioids and other controlled substances.

Our leaders should also implement common-sense solutions to close the opioid access back door including banning the use of anonymous PBM cash discount cards for filling opioid prescriptions and requiring digital ID verification at the time-of-purchase for all opioids and schedule II restricted pharmaceuticals.

These easy to implement measures will provide stronger and more genuine opioid prescription controls to better address this devastating health crisis.

Kelly AyotteKelly Ann AyotteBottom line Seven Senate races to watch in 2022 Bottom line MORE is a former attorney general of New Hampshire and U.S. Senator from the state. She was a lead co-sponsor of the Comprehensive Addiction and Recovery Act. Kelly is an advisor to Blink Health.