The Drug War Extends To Medicare Patients

There is wide spread consensus that opiates were overused in the past, and their use has been greatly curtailed in recent years. Many people were placed on high doses for chronic pain when this was considered the standard of care, and the pharmaceutical industry did all it could to promote this practice. The problem is many people who are using high doses safely and responsibly are now being targeted by government efforts to decrease opiate use. While it makes sense to limit new prescriptions, and decrease their use in long-time users when possible, the government has been going overboard in intervening in patient care to decrease their use.

Both in January 2016 and January 2017 I encountered cases where Medicare drug plans abruptly reduced the doses of pain medications they would approve, and Medicare is now considering far more draconian cuts as of January 2018. This is largely based upon distorting recommendations from the Centers for Disease Control, with even writers of those guidelines protesting actions by the Medicare plans. Some patients have tried to get around this by paying for part of their prescriptions, but I have recently been informed by local pharmacists that they are now under pressure to stop filling prescriptions for amounts beyond what is approved. This is driving some to the use of cheaper street drugs such as heroin, increasing the risk of overdoses, contrary to the stated goals of regulations to reduce opiate use.

The New York Times has an excellent article on the situation. I have some excerpts below, but recommend reading the full article.

Medicare officials thought they had finally figured out how to do their part to fix the troubling problem of opioids being overprescribed to the old and disabled: In 2016, a staggering one in three of 43.6 million beneficiaries of the federal health insurance program had been prescribed the painkillers.

Medicare, they decided, would now refuse to pay for long-term, high-dose prescriptions; a rule to that effect is expected to be approved on April 2. Some medical experts have praised the regulation as a check on addiction.

But the proposal has also drawn a broad and clamorous blowback from many people who would be directly affected by it, including patients with chronic pain, primary care doctors and experts in pain management and addiction medicine.

Critics say the rule would inject the government into the doctor-patient relationship and could throw patients who lost access to the drugs into withdrawal or even provoke them to buy dangerous street drugs. Although the number of opioid prescriptions has been declining since 2011, they noted, the rate of overdoses attributed to the painkillers and, increasingly, illegal fentanyl and heroin, has escalated.

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

Dr. Stefan G. Kertesz, who teaches addiction medicine at the University of Alabama at Birmingham, submitted a letter in opposition, signed by 220 professors in academic medicine, experts in addiction treatment and pain management, and patient advocacy groups.

His patients include formerly homeless veterans, many of whom have a constellation of physical and mental health challenges, and struggle with opioid dependence. For them, he said, tapering opioids does not equate with health improvement; on the contrary, he said, some patients contemplate suicide at the prospect of suddenly being plunged into withdrawal.

“A lot of the opioid dose escalation between 2006 and 2011 was terribly ill advised,” Dr. Kertesz 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.”

Some two dozen states and a host of private insurers have already put limits on opioids, and Medicare has been under pressure to do something, too. Last July, a report by the inspector general at the Department of Health and Human Services raised concerns about “extreme use and questionable prescribing” of opioids to Medicare recipients. In November, a report from the Government Accountability Office took Medicare to task, urging greater oversight of opioid prescriptions…

Opponents of the new limit say that doctors are already overwhelmed with time-consuming paperwork and that many will simply throw up their hands and stop prescribing the drugs altogether.

A delay or denial would put chronic pain patients — or those with inflammatory joint diseases, complex shrapnel injuries or sickle cell disease — at risk of precipitous withdrawal and resurgence of pain, doctors said.

The Medicare proposal relies on guidelines from the Centers for Disease Control and Prevention that say doctors should not increase an opioid to a dose that is the equivalent of 90 milligrams of morphine.

But experts say that Medicare misread the recommendations — that the C.D.C.’s 90-milligram red flag is for patients in acute pain who are just starting opioid therapy, not patients with chronic pain who have been taking opioids long-term. The acute pain patient, the guidelines say, should first be offered treatments like acetaminophen or ibuprofen. A short course of a low-dose opioid should be a last resort.

“We didn’t take a specific position on people who were already on high doses,” said Dr. Lewis S. Nelson, the chairman of emergency medicine at Rutgers New Jersey Medical School and University Hospital, who worked on the guidelines.

“We did say that established, high-dose patients might consider dosage reduction to be anxiety-provoking, but that these patients should be offered counseling to re-evaluate,” he added. “There is a difference between a C.D.C. guideline for doctors and a C.M.S. hard stop for insurers and pharmacists.”

Dr. Erin E. Krebs recently released a comprehensive study showing that patients with severe knee pain and back pain who took opioid alternatives did just as well, if not better than, those who took opioids. Nonetheless, she and seven others who worked on the C.D.C. guidelines signed the letter opposing the Medicare rule.

“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,” said Dr. Krebs, an associate professor of medicine at the University of Minnesota.

“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,” she added. “We have created a double tragedy for these people.”

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2 Comments

  1. 1
    Veronica Birkland says:

    I was on Tramadol and Oxycontin in the hospital for 3 weeks straight.  After I was on them at home for awhile,  I forgot to take the Tramadol (deadliest drug in America) and immediately went into withdrawal.  Here are the symptoms: twitching muscles, nausea, sweating and constant diarrhea.    After 3 days of this,  it was over,  but I am so glad I got off!

  2. 2
    Ron Chusid says:

    There is general agreement to reduce the amount of opiates used post-op (although I hope they don’t go too far in the other direction). This is dealing with people already on them for years. If you had problems after a few weeks, imagine the problems if we try to rapidly wean people who have been on them for years.

    I wouldn’t call Tramadol the deadliest drug in America. While individuals definitely differ, I’ve seen far more people have problems with Oxycontin than Tramadol

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