New limits for high-dose opioid prescriptions will be enacted next year for Medicare Part D users, the Centers for Medicare & Medicaid Services (CMS) announced on April 2. Prescriptions will be held to a standard of 90 morphine equivalent milligrams (MME) per day, which follows the CDC prescribing guidelines for primary care physicians released last year.
The Medicare announcement—part of the 2019 Medicare Advantage and Part D Rate Announcement and Call Letter—also sets limits for opioid-naive patients on seven-day prescriptions, and notes the expansion and combination of the Overutilization Monitoring System and other government facets to identify “high-risk” opioid users, defined as using high levels of opioids from multiple sources, and “potentiator” users, who are using other medications (e.g., benzodiazepines) that increase the risk for adverse effects from opioids. CMS also plans to increase education on overdose risk and prevention.
With around 42.8 million people enrolled in Medicare Part D as of 2017, and a precedent for setting industry example, the agency hopes to “address the opioid epidemic” with these limits, aiming for an “overall reduction in opioid overuse and overdoses.”
The limits will not affect patients in long-term care facilities, hospice, palliative care or those effected by cancer-related pain. It also excludes patients seeking medication-assisted treatment for opioid addiction, such as those on buprenorphine.
Some research has shown higher doses can be correlated with overdose. A Veterans Health Administration sample of chronic pain showed overdose patients had an average dosage of 98 MME per day, compared with other patients who had an average of 48 MME per day. The CDC also said an opioid dosage at or above 50 MME per day doubles the overdose risk, compared with dosages less than 20 MME per day. The standard of 90 MME per day now set by Medicare is equivalent to 90 mg of hydrocodone per day, 60 mg of oxycodone or about 20 mg of methadone.
But the average number of daily MME per prescription has been declining, from 60 to 50 MME per day between 2006 and 2015, according to numbers from the CDC. Those with high-dose prescriptions (≥90 MME per day) also have declined, to an average 6.7 per 100 people in 2015. And overall prescriptions are down, at around 70 per 100 persons that same year, although that number is still three times higher than in 1999.
we know that opiate prescriptions have been declining annually since 2012 and they are using TWO YEAR OLD DATA – 2015 and using generally accepted national averages upward to 10% of the population could be classified as suffering from incurable intractable chronic pain – requiring 24/7 opiate therapy. With the CMS quoted numbers – using 2015 data – they believe that with 30% of that group of pts being untreated properly is STILL TOO HIGH..
CMS is also using opiate conversion ratios that are stated as.. FACTS … where are in fact… “HIGHLY CRUDE ESTIMATES”… and apparently there is no pt accommodation for the pt being fast/ultra fast opiate metabolizer.
Here is four quotes from the CDC opiates guidelines:
https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”
“Clinicians should consider the circumstances and unique needs of each patient when providing care.”
“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”
“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”
It would also appear that CMS’ recommendation COMPLETELY IGNORES the above parts of the CDC opiate dosing guidelines.
It would also appear that CMS is dead set on discriminating against a segment of our society that is consider a “protect class” under the Americans with Disability Act and the Civil Rights Act. Since the federal agency that is in charge with enforcing the ADA https://www.ada.gov/filing_complaint.htm is under the same agency as the DEA – Dept of Justice. AND… since CMS and CDC are part of HHS…
Is it just me… or does there seem to be a great deal of collusion and cross protection of the actions of various Federal agencies by other Federal agencies ?
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