Medicare Finalizes Opioid Restriction Plan That Will Massively Impact Pain Patients

By Kelly Burch 04/03/18

Doctors believe the strict, new policy will have negative health consequences for pain patients. 

woman in pain holdng her upper arm

On Monday, Medicare revealed a host of new policy changes for 2019 including a policy that will prevent the government insurance program from covering long-term, high-dose opioid prescriptions—a vast change for the program, which had one-third of beneficiaries prescribed opioids in 2016.

Here's are a few of the final, updated policies:

  • Medicaid plan sponsors will implement a hard safety edit to limit initial opioid prescription fills for the treatment of acute pain to no more than a 7-day supply for new opioid users.
  • For chronic opioid users, Medicare plan sponsors will implement real-time safety alerts at the time of dispensing, as a proactive step to engage both patients and prescribers about overdose risk and prevention.
  • Medicare plan sponsors will implement additional soft safety edits to alert the pharmacist about duplicative opioid therapy and concurrent use of opioids and benzodiazepines.

Doctors—even those well-versed in the dangers of opioids—say that the new policy to taper the drugs is a governmental overreach that could have negative health consequences for patients. 

“The decision to taper opioids should be based on whether the benefits for pain and function outweigh the harm for that patient,” Dr. Joanna L. Starrels, an opioid researcher and associate professor at Albert Einstein College of Medicine, told The New York Times. “That takes a lot of clinical judgment. It’s individualized and nuanced. We can’t codify it with an arbitrary threshold.”

Under the new policy, which will take effect in January 2019, Medicare would not cover opioid prescriptions that last for more than a week and are equal to 90 milligrams of morphine daily (the morphine equivalency is a standard way to measure the power of opioid prescriptions).

There would be exceptions for cancer patients and those in hospice. The change would affect an estimated 1.6 million of the 43.6 million Medicare recipients. 

Two hundred and twenty experts in medicine, addiction treatment and pain management, as well as patient advocacy groups, have signed a letter opposing the policy change. 

Dr. Stefan G. Kertesz, who teaches addiction medicine at the University of Alabama at Birmingham, said that he has had patients consider suicide when faced with the prospect of being weaned to a lower dose of their pain medication. 

“A lot of the opioid dose escalation between 2006 and 2011 was terribly ill advised,” he said. “But every week I’m trying to mitigate the trauma that results when patients are taken off opioids by clinicians who feel scared. There are superb doctors who taper as part of a consensual process that involves setting up a true care plan. But this isn’t it.”

A recent study found that opioids are no more effective than over-the-counter and non-opioid alternatives for relieving chronic pain. However, Dr. Erin E. Krebs, the lead author of that study, signed the opposition letter to Medicare. 

“My concern is that our results could be used to justify aggressive tapering or immediate discontinuation in patients, and that could harm people—even if opioids have no benefit for their pain,” she said. “Even if we walk away from using opioids for back and knee pain, we can’t walk away from patients who have been treated with opioids for years or even decades now. We have created a double tragedy for these people."

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Kelly Burch writes about addiction and mental health issues, particularly as they affect families. Follow her on TwitterFacebook, and LinkedIn.