Some physicians are pushing back against “widespread misapplication” of the 2016 federal opioid prescribing guidelines, while a new report from Harvard Medical School researchers gives some credence to their claims.
Some 300 health professionals signed a joint letter to the director of the Centers for Disease Control and Prevention to issue “a bold clarification” of the CDC’s policy on tapering long-term users of pain medications off of the drugs. The letter says that after the guidelines were adopted, many doctors and regulators incorrectly believed that the CDC had established a daily dose limit of 90 mg of morphine equivalent and imposed payment barriers and explicit taper plans as a condition for authorizing refills.
“Taken in combination, these actions have led many health care providers to perceive a significant category of vulnerable patients as institutional and professional liabilities to be contained or eliminated, rather than as people needing care,” the letter states.
The long-awaited federal opioid guidelines were lauded by workers’ compensation carriers as a means of curtailing opioid abuse and addiction. Increased attention to opioid over prescribing is credited with reducing carriers’ spending on pharmaceuticals. A study published by the Journal of the American Medical Association found that 30% of workers’ comp claimants who were treated with opioid continued to use them beyond 90 days after injury. Other research has shown persistent opioid use is associated with poor claim outcomes.
But the physicians who wrote the CDC said insurers and other payers have invoked the guideline’s dose thresholds as binding for purposes of payment, determinations of quality of care, and professional and legal liability for physicians. “As a result, patients on stable opioid dosages have faced draconian and often rapid involuntary dose reductions, often resulting in grave harms” according to a press release from the University of Alabama.
Professor Stefan Kertesz, a physician and addiction specialist who teaches at the university, said he endorses the guideline’s message that opioids should “rarely” be a first option for chronic pain.
“We know the harm wrought by reckless promotion and prescribing of opioids for the last 20 years, and we are still compelled to respond to the loss of human life, as medications are cut off and patients abandoned,” Kertesz said in a prepared statement. “Since all the parties involved cite the CDC as justification, it comes down to whether the CDC will merely whisper about this problem or take clear action to protect patients who are increasingly at risk” The letter’s 321 signatories include 126 medical school faculty.”
Signatories to the letter include three former U.S. “drug czars”: Jerome Jaffe (1971-73), Gen. Barry McCaffrey (1996-2001), and Michael Botticelli (2014-2017).
A study released by the Harvard Medical School on Wednesday showed that the nationwide effort to curtail opioid prescribing has shown dramatic results. An analysis of more than 86 million privately insured patients across the United States between 2012 and 2017, published Wednesday in the New England Journal of Medicine, found a 54 percent decrease in the rate of monthly opioid prescriptions to patients who have never previously used the drugs or had been off them for at least six months. The number of providers who prescribed opioids for any “opioid-naive” patient decreased by nearly 30 percent, according the study.
The researchers found their findings both reassuring and alarming, according to a press release from Harvard Medical School. The report found that some doctors have ceased any new prescriptions for opioid pain relief, raising the question of whether some patients might be getting less-than-adequate treatment for their pain.
“The challenge we have in front of us is nothing short of intricate: Curbing the opioid epidemic while ensuring that we appropriately treat pain,” stated Nicole Maestas, senior investigator on the study and associate professor of health care policy in the Blavatnik Institute at Harvard Medical School. “It’s a question of balancing the justified use of potent pain medications against the risk for opioid misuse and abuse.”
For its part, the CDC says it is well aware that its guidelines are not hard and fast dosage limits and it has communicated that message to health care providers.
“The CDC Guideline does not endorse mandated or abrupt dose reduction or discontinuation,” said Courtney N. Lenard, senior press officer for the CDC’s National Center for Injury Prevention and Control, in an email to the Claims Journal.
Lenard said the guideline asks physicians to avoid or carefully justify increasing dosages above the threshold. The document also offers different guidance for patients already above the stated threshold, including reviewing risks and benefits of continuing high-dosage therapy, offering to taper, and for patients who agree to taper, collaborating with the patient on an individualized that is slow enough to minimize opioid withdrawal, she said.
The CDC published a pocket guide after release of the guideline emphasizing those principles. The agency is also conducting research to ensure that it can continually improve the guideline. It has ommissioned a chronic pain systematic review by the Agency for Healthcare Research & Quality to determine what new scientific evidence has been released since the guideline was released in March 2016, Lenard said.
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