Docs warn that Medicare crackdown will hurt pain patients

http://www.politico.com/story/2017/03/docs-warn-that-medicare-crackdown-will-hurt-pain-patients-235917

A group of prominent pain and addiction specialists are pushing back against the federal opioid crackdown by asking CMS to withdraw a notice that would make it extremely difficult for Medicare patients to get painkiller prescriptions above a certain strength.

More than 80 physicians, including four who helped create the 2016 CDC guidelines on opioid prescribing, wrote to acting Medicare director Cynthia Tudor about the notice, which would require pharmacists to refuse prescriptions over 90 milligrams of morphine or its equivalent unless the patient first went through a complex, time-consuming review.

While the CDC guidelines caution that high doses create an overdose risk, they also state that physicians should have ultimate discretion on prescribing, and warn that it is not advisable for patients to be tapered off high doses of opioids involuntarily.

An estimated 5-8 million Americans use opioids to treat chronic pain. Many were started on the drugs before the risks were recognized. A 2008 study showed that half of non-cancer opioid patients in Medicaid and private insurance were getting doses above the threshold. While tapering off high doses is often advisable, pain doctors say it must be done carefully and with patient consent.

“CMS mandates will cause previously stable patients to suffer acute withdrawal with or without medical complications, including death,” says the letter, which states that the CMS rule, buried deep within a Feb. 1 CMS payment document, is “in tension with the spirit and the letter of the CDC Guideline.”

Pain and addiction specialists largely agree that doctors saddled too many patients with high doses of opioids in the decade before 2010. Yet some of these patients are medically stable on high doses, and others can’t access the complex care needed to wean them off without tremendous suffering.

“There’s little question that the license given to doctors to reduce pain … was too much,” said Jeffrey Samet, past president of the American Board of Addiction Medicine. “But the pendulum has swung too far in the opposite direction.”

To be sure, there were more than 20,000 deaths linked to prescription painkillers in 2015. Since 2012, though, opioid prescribing and deaths have gradually declined, while deaths from heroin and fentanyl, a powerful synthetic opioid, continue to skyrocket.

“What caused the epidemic and what sustains it today are not the same,” said Stefan Kertesz, a University of Alabama internist and addiction specialist.

The comment period for the CMS rate announcement rule, which takes effect April 3, ended last Friday. Asked to respond to the critique, CMS said its notice followed CDC expert guidelines.

CMS is not the only agency that is tightening the screws on high-dose prescribers.
Under new guidelines under consideration by the National Committee for Quality Assurance, health care providers who provide patients more than 120 milligram morphine equivalents daily over a three-month period would have points taken off from their quality scores.

Already, prescription drug monitoring programs are getting better at detecting patients who doctor shop and doctors who overly prescribe. Many doctors have cut doses or “fired” high-dose patients, and there are anecdotal reports of suicides and heroin deaths among patients who lost access to the medications they were using.

Some of these patients are in such pain that the “just lie in bed or watch TV all day,” said James DeMicco, whose Hackensack, N.J., pharmacy services a major pain clinic. About two-thirds of the opioid patients he serves get more than the CMS-proscribed dose, he said.

The CMS rule could inconvenience pain patients without having much impact on mortality, Kertesz said, because opioid fatalities are increasingly heroin-related.

Data from Birmingham, Ala., for example, show that since 2010, prescription opioid deaths have stabilized at about 50 per year, while heroin deaths surged from 3 in 2010 to 92 in 2016, and fentanyl deaths jumped from 0 to 92. In Cleveland, where 494 people died of opioid overdoses in the first eight months of 2016, 424 were from fentanyl. In Massachusetts, only 8 percent of those who died of overdoses over a three-year period had been prescribed opioids at the time of their deaths.

Though skeptical of the CMS rule, many pain and addiction specialists agree that most high-dose patients would function better if tapered down. They are also less likely to die of an overdose, notes Paul Hilliard, chairman of the Hospital Pain Committee at the University of Michigan health system.

“Blanket statements and policy should never substitute for sound clinical judgment,” said Hilliard. “I do, however, support the notion that any patient on high-dose opioids deserves a review of the medication and treatment strategy. “

“I just don’t see that many patients on high doses who are working full time, coaching the kids’ soccer team, or volunteering at soup kitchens,” he said. “And they continue to report high pain levels.”

Patients who benefit from high doses of opioids are “more the exception than the rule, in my practice,” said Jane Liebschutz, a Boston Medical Center physician. “But the ones who do need it I’d go to bat for. The rules CMS is putting out would make it more difficult for patients and doctors.”

Federal officials have been campaigning hard against prescription drug abuse but are beginning to show concern about unintended consequences.

In a New England Journal of Medicine article in December, Surgeon General Vivek Murthy noted that while prevention and increased treatment are needed to lower opioid abuse, “we have to do all these things without allowing the pain-control pendulum to swing to the other extreme, where patients for whom opioids are necessary and appropriate cannot obtain them.”

NIH officials are also wary of unintended consequences. Federal surveys show that roughly 80 percent of heroin users got started on opioids through prescription drugs.

There is no evidence that pain patients weaned off of opioids turn to heroin in large numbers, but it’s possible that street drugs can become an option “when their other drug of choice becomes unavailable,” and the issue needs more study, said Wilson Compton, deputy director of the National Institute of Drug Abuse.

Doctors who decide to taper off an addicted patient need to help find them treatment, he said. But treatment is expensive and waiting lists to get into decent programs are long in opioid epidemic-stricken regions of the country. A new law would vastly expand treatment, but first Congress has to fund it.

 

 

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