In response to the opioid overdose crisis, federal Medicare officials are considering new rules that would discontinue payment for long-term, high-dose opioid therapy beginning in 2019. The vote on the new rules takes place Monday.
This is an ill-advised approach. Currently, some 1.6 million people receive opioid medication through Medicare equivalent to 90 mg per day of morphine or more. Sharp cutbacks in doses will result in hundreds of thousands of men and women with chronic pain developing withdrawal, craving and poor pain control.
{mosads}While I too have deep concern about the opioid epidemic gripping our country, this outrageously short-sighted plan by the federal Centers for Medicare and Medicaid Services has the potential to cause grave harm. It could drive hundreds of thousands of people to extreme measures to avoid unintended and profoundly miserable outcomes.
Moreover, the proposal doesn’t address the real cause of most opioid overdose deaths. Earlier on in the opioid epidemic, most overdose deaths and emergency department visits resulted among chronic pain patients who were taking prescription opioids. But since then, the opioid epidemic has rapidly transitioned into an illicit drug problem.
Yet the dose-reduction proposal is aimed at this old problem, and seems blind to the current reality. To be clear: Drastic dose reductions for patients who are physically dependent on opioid therapy too often causes individuals to turn in desperation to far more dangerous and addictive illicit drugs like fentanyl and heroin.
We must do all we can to prevent individuals from developing addiction to these street drugs. Heroin and fentanyl are readily available, inexpensive, highly purified, look identical to prescription painkillers, and are peddled the same way pizzas are delivered.
In my state of North Carolina and others around the nation, the situation is rapidly deteriorating, with far more people overdosing and dying from street-purchased opioids than from prescription painkillers.
The Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, the de facto standard for safe opioid practice in our country, recommends that prescribers “should avoid increasing dosage to 90 mg of morphine or equivalent (MME) or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day.” The new proposal flies in the face of these expert recommendations by mandating lower dosages, rather than allowing doctors to make reasoned decisions.
The CDC Guideline also contains extensive safety measures, widely agreed upon though largely ignored by prescribers.
Why is this? The answer, as usual, is time and money. Prescribers of opioid medications struggle to see their patients in busy clinical environments, typically typing their own notes into electronic health records and performing numerous clerical tasks. The right and time-consuming thing to do is check state databases for evidence of controlled substance abuse such as doctor or pharmacy shopping, to provide detailed education on opioid safety, to remind patients about safe storage and disposal of leftover medication, and to explain how prescription naloxone is an important safety measure.
But no Medicare payment codes cover these important activities, and this is a major disincentive for health care providers. If that were changed, medical practices could hire additional staff to serve as stewards of opioid safety. Doctors could then do much more to reduce unintentional overdoses and prevent opioid addiction in a safe and compassionate way.
Instead of pursuing the profoundly misguided and ultimately cruel strategy represented by the proposed new guidelines, Medicare could take the lead in providing the financial support medical practices and health systems need to implement safe prescribing strategies.
In addition, Medicare could implement barriers to discourage prescribers from increasing doses to unnecessarily high levels. North Carolina’s Medicaid program, in which I serve an active role in drug policy, recently opted to require prior authorization paperwork for any such prescriptions.
Sound public policy should reduce the prescribing of high doses of opioids and improve the safety of individuals currently treated with opioid therapy. And most importantly, it must actively strive to prevent new instances of addiction to opioid street drugs, now by far the biggest cause of overdose deaths.
Inflicting unnecessary additional misery to those whose pain is treated with high-dose opioids seems destined to result in more suffering and would actually fuel the addiction crisis.
Lawrence Greenblatt, M.D. is co-chair of the Opioid Safety Committee at Duke Health and chairs the North Carolina Medicaid Pharmacy and Therapeutics Committee.