Prescribed pain pills can be abused. Some say the tests for drug abuse are being abused, too.

Whirl of Pain

Written by Tom Marcinko Category: Valley News Issue: May 2016
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PHM0516PF WP 01Sometimes the cost of pain treatment engenders another kind of pain: the financial kind. In one story recently relayed in The Arizona Republic, Eric Smith of Phoenix got socked last year with a $660 bill from Arizona Pain Specialists – not for his Percocet, prescribed to ease the pain of a degenerative disc, but for urine tests to ensure he was taking his meds as ordered, and not taking drugs he shouldn’t. Another patient at the same practice, a 75-year-old Fountain Hills man, got billed $1,048 for similar tests, the Republic reported.

While opioid painkillers can be a godsend for the 100 million Americans who suffer chronic pain, some patients and insurance providers say tests to prevent abuse are often overused, and the bills can really hurt. Labs can profit at the expense of patients and insurers, and doctors who take kickbacks have had their licenses suspended by the Arizona Medical Board, which mandates drug-testing but doesn’t specify how many tests or how often. 

This year Medicare started to fight the problem by capping the number of tests a practice can bill the government for, and limiting payments. “Each drug class may only be billed once per day per beneficiary,” says Jack Cheevers, California spokesman for the U.S. Centers for Medicare and Medicaid. He calls the new system simpler and more transparent, and says it will reduce incentives to overbill and overtest.

Former employees of one testing lab, Millennium Health (formerly Millennium Laboratories) in San Diego, described to Reuters in 2012 how the company tried to persuade physicians to order excessive tests. A single test costs about $15, but the company tried to lure doctors to request 11 different tests on every sample, for about 20 patients per day. 

Millennium filed for bankruptcy last year after settling a $256 million lawsuit with the U.S. Justice Department for overbilling Medicare, Medicaid and other federal agencies. Insurance giant Cigna is suing a Florida lab called Sky Toxicology over billing practices. 

“In general, we appear to have a problem with the commercial labs marking their tests up quite a lot,” says Dr. Gretchen Alexander, a psychiatrist with Maricopa Medical Center and president-elect of the Arizona Medical Association (ArMA). “And it looks like the drug screening tests are no exception.” 

But such tests are necessary, she says, pointing to a 2014 Centers for Disease Control and Prevention study showing that three out of four heroin users say they started out by abusing prescription opioids. Many patients have pain-drug prescriptions from different doctors, she says. And some patients test negative for any pain meds, which suggests they may be selling their drug supply. 

“Drug testing is necessary to screen for all of those behaviors,” Alexander says. In 2014, one Arizonan died every day from opioid abuse, according to the Arizona Medical Association. The state ranks 12th nationally for overdose death rates and for drug abuse and misuse among people age 12 and older.

There’s little evidence that drug tests deter abuse or prevent overdoses, says Dr. Robert “Chuck” Rich Jr., chair of the American Association of Family Physicians’ commission on public health and science. “But it is one of the few tools available,” he adds. Many government programs pay $20 per test, but if the first test shows nothing unusual, “There is no need to do a more expensive confirmatory test.”

Cheevers says the system could be a lot more transparent. Patients often don’t know why they are being tested, or for which drug: “Even the ordering physician may not know the number or composition of tests being performed” in response to a test order. “When the tests are billed separately, they are more expensive than when the tests are billed together.” 

State Sen. John Kavanagh introduced a bill to mandate that doctors and pharmacists consult a state database of opioid and benzodiazepine users before they write new prescriptions. The measure addresses abuse, not overbilling, says Kamlesh Gandhi, executive director of the Arizona State Board of Pharmacy, which would create the database. But on the overbilling problem, he says, “It might help.”