Opioids

New Medicare Rule Promises Needless Suffering for Pain Patients

Taking a cue from the CDC, the proposed regulation imposes an arbitrary cap on opioid prescriptions.

|

Casey Fleser / Flickr

The CDC's controversial but officially optional opioid prescription guidelines, which encourage doctors to be as stingy as possible with pain medication, seem to be getting more mandatory every day. The recommendations, which were published in March 2016, already have been imposed on veterans, incorporated into state laws, and adopted as a guide to proper medical practice by regulators, insurers, and doctors. Now the Trump administration plans to impose them on the 44 million Americans enrolled in Medicare, against the advice of critics who say that move will lead to needless suffering. Those critics include doctors who helped produce the guidelines.

For patients suffering from severe chronic pain, the most problematic aspect of the guidelines is the recommendation that doctors "should avoid increasing dosage" above 90 morphine milligram equivalents (MME) per day, or at least "carefully justify a decision to titrate dosage" above that level. Critics say that threshold, which many doctors have interpreted as a hard cap, is arbitrary because patients vary widely in the way they metabolize and respond to opioids, especially if they have developed tolerance after taking pain medication for years. Thanks to the CDC's advice, patients across the country have seen their doses dramatically reduced, even when they had been responding well to opioids for years.

Lynn Webster, a former president of the American Academy of Pain Medicine (AAPM), hears from such patients almost every day. He says opioids enabled them to "have a reasonable life…maybe for a decade or more," but "many of them are now bedridden, because they're being forced to take a dose far less than what has been necessary to keep them functional."

The Trump administration seems determined to replicate that pattern among Medicare recipients. Under a proposed rule that is expected to take effect in January, Medicare will not cover pain medication amounting to 90 MME or more a day for more than a week, except for cancer and hospice patients. According to the Centers for Medicare and Medicaid Services (CMS), 1.6 million patients currently exceed that cap. That means many patients with severe chronic pain will have to choose between agony and paying thousands of dollars more every year for their medication, assuming they can afford it.

"While a strong case can be made for consensual, supported opioid dose reductions for voluntary patients, no data support nonconsensual/forcible dose reductions or curtailment in otherwise stable patients that have become common as prescribers react to regulations, mandates, insurers and fear for professional security," say 150 physicians in a letter to CMS criticizing the new policy. "The CMS plan risks accelerating a chaotic pattern of churn, abandonment and medical harm to patients who receive opioids as physicians flee an increasingly risk-laden and cumbersome decision matrix that may not advance patient safety."

Stefan Kertesz, the University of Alabama at Birmingham pain and addiction specialist who spearheaded that letter, notes that several experts who worked on the CDC's guidelines have expressed concerns about the proposed CMS limits. One of those CDC advisers, University of Minnesota internist Erin Krebs, told The New York Times she worries about "aggressive tapering or immediate discontinuation," which "could harm people, even if opioids have no benefit for their pain." Krebs emphasized that "we can't walk away from patients who have been treated with opioids for years or even decades now."

Another doctor who worked on the guidelines, Lewis Nelson, chairman of emergency medicine at Rutgers New Jersey Medical School and University Hospital, told the Times: "We didn't take a specific position on people who were already on high doses. 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 that "there is a difference between a CDC guideline for doctors and a CMS hard stop for insurers and pharmacists."

Deborah Dowell, a co-author of the guidelines, likewise has insisted that the CDC did not intend to encourage involuntary tapering or cessation. "We do hear stories about people being involuntarily taken off opioids," she said at an April 2017 conference. "We specifically advise against that in the guidelines." That's not exactly true, although the guidelines do describe tapering as a consensual process.

Webster says the CDC, given its status within the medical community, should have known that its advice would be interpreted as a mandate. "The CDC bears full responsibility for how these arbitrary dose levels are being implemented throughout the country and the consequences for the people in pain," he says. "I said at the time when they were proposed that if something comes from the CDC as a guideline, it is more than a guideline. It will be interpreted basically as a level of dosing that if you exceed [it], then you are at legal jeopardy."

Advertisement

NEXT: No Arbitrary Power: An Originalist Theory of the Due Process of Law

Editor's Note: We invite comments and request that they be civil and on-topic. We do not moderate or assume any responsibility for comments, which are owned by the readers who post them. Comments do not represent the views of Reason.com or Reason Foundation. We reserve the right to delete any comment for any reason at any time. Report abuses.

  1. Critics say that threshold, which many doctors have interpreted as a hard cap, is arbitrary because patients vary widely in the way they metabolize and respond to opioids…

    Well, if you can think of a better way for a central bureaucracy to wrest control of patient care besides one-size-fits-all regulation, I’d like to hear it.

    1. I am now making a good salary online from home as last month I have received $25346 by doing simple and easy work online from home look here more

      http://www.richdeck.com

  2. …although the guidelines do describe tapering as a consensual process.

    “You consent to taper down dosages and we consent to not arresting you and your doctor.”

  3. Explain to me again the part where it’s a good idea to put the government completely in charge of the healthcare system.

    1. Because EVUL KKKOCHPORAT PROFITSES!!1!!1!!!!!!!1!!!!!!

  4. Pain patients could solve this easily – just infiltrate your local 12 Step groups and meet the manipulative losers (aka ‘addicts’) for whose sins you are suffering and dying. I have no doubt you’d put a stop to this nonsense in no time.

  5. 1.6 million patients currently exceed that cap.

    MILLION

    It’s absolutely insane to think that a revocation of free choice that affects 1.6 MILLION people can be entirely without negative consequences.

    1. I predict a sharp increase in suicides and accidental overdoses as pain patients attempt to supplement their meager CDC allowance with street drugs.

      1. Which will, of course, only poor fuel on the opiod crises moral panic fire.

    2. This is not a revocation of choice.

      This is an implementation of a limit.

      The patient is free to use their own money to buy additional narcotics if they so desire and the physician chooses to prescribe them.

      That is, in fact, ‘free choice’ and the libertarian way for everyone involved in this.

      If people don’t like the payer limit, they need to get off the gov’t insurance program.

      1. True but the larger issue is that doctors are reluctant to prescribe above that level because the CDC “guidelines” are seen as a mandate so the dosage is unavailable under any circumstances outside the black market.

        1. That has nothing to do with this limitation of the use of taxpayer dollars to buy people’s drugs.

      2. That is so full of bovine fecal material that I can smell it right off of the computer! The dose has no reason to be determined by authoritarian old ladies, who know nothing about titration and dose of pain medication. They know nothing about determining the dose that any one person should be using. The entire thing is arbitrary and capricious! Saying that limiting the dose is not limiting the ability of poor, old people, to be properly be relieved of their suffering is nuts! Those people, who treat chronic pain this way, are just using us as pawns! No one cares about the old folks’ suffering. They just want to spout out this BS, denying the fact that proper dosing for chronic pain patients should be determined by the doctor and his patient. With the overdose rate going up, in spite of the draconian cutbacks, it seems to be proof enough that the jerks have no idea what in the hell they are doing. We are cutting back on a group with less than 0.5% addiction rate. I get mad sometimes and have this opinion flood into my head that the addicts get what they deserve. They have screwed plenty of people’s lives up with their selfish behavior. Why should old people consider suicide because they cannot get their suffering properly treated. Isn’t that the main crux of medicine? isn’t it our responsibility to relieve suffering?. The suffering, that the addicts afflict upon themselves, is not what should be worrying all of us who follow the darned rules!

        1. The blame game directed at the doctors, is 180 degrees off of what the truth reveals! It is caused by people who think they can abuse opiates without becoming addicted. They just abuse the drugs, ignoring what is going to happen! Their lack of responsibility is what should be addressed!

          1. Exactly. We have an addict problem, NOT an opioid problem.

            Fucking idiot leftists are always blaming the tool, not the people. Opioids, guns, you name it– unless they can blame it on Team Red somehow.

        2. Go fuck yourself.

          Let me tell you about two recent patients.

          One of them had a small abscess, so small it did not meet criteria for drainage. When I informed the patient that it did not require drainage and could be treated with antibiotics, he immediately started harassing me to prescribe opiates to treat the excruciating pain he claims to be having from an abscess that was about the size of a nickel. Never mind that he had not used a single milligram of anything he could obtain over the counter.

          Another patient came in obviously intoxicated with a level that was four times that to disqualify him from driving. The kicker was that he had just been discharged from another hospital that morning where he had been dropped off in an extreme state of intoxication. He had sobered up, and then been discharged, whereupon he managed to get himself intoxicated again in short order. He was still wearing his ID band and EKG electrodes from the other hospital. It’s in the evening on a weekend and he demands that I prescribe him benzodiazapines so he can detox at home. I ask if he has any intention of getting sober, and he says no. He lost his shit in the department for about 40 minutes when I informed him he wasn’t getting a benzo prescription.

          The elderly are not the problem.

          The people I mentioned above are the problem.

          I didn’t screw up anyone’s life; those people did it on their own, and now want me to enable their dysfunction.

          Clinicians like myself can tell the difference.

      3. You’re a fucking idiot.

        What physician is going to go against the government and prescribe them, at the risk of being told by the government that they can’t be a physician any more?

        There’s no “free choice” at all here, slaver.

        I hope you get struck with crippling pain and are denied any and all painkillers, you fucking ghoul.

  6. “The CDC bears full responsibility for how these arbitrary dose levels are being implemented throughout the country and the consequences for the people in pain,”

    No, they bear no responsibility whatsoever. That’s precisely why they issued a guideline – “I’d strongly suggest, if you know what’s good for you…” – rather than an order, it lets them completely evade any responsibility. That’s Bureaucracy 101 – never issue an unambiguous directive which leaves no wiggle room for claiming your instructions were misinterpreted.

  7. Soon, we will have the prescribing doctor hand us one pill at a time, time-spaced, for immediate consumption only… For $500 each! This is a FEATURE, not a BUG!!!

    Doctors can then make YUUUUGE campaign contributions!!!!

  8. I must admit I clenched up a bit when I started hearing anti-dope advocates say things like “We have to get over the idea that we should be totally pain free during an illness or after surgery.” Yeah, fuck that.

    1. It’s almost like politicians and bureaucrats don’t necessarily have your best interests at heart (and/or don’t know what they are). Strange.

    2. I never saw one pain patient that wanted 100% relief from their pain! It never happened after surgery, or in chronic pain patients. That was one of the reasons the ‘pain scale” was developed. Adjusting the dose, to make the patients get adequate relief, was much easier. I just figured out a way to let people experience my pain. We could put a TENS unit on them, and turn it up to a “10” pain. We could tell them to ‘live with it”, for just one hour! They would not be so pompous about the pain that we chronic pain patients suffer! it is just insane to think that any one physician or nurse could determine how much pain another person was suffering! I cannot tell how much pain someone else has by looking at them! it was the only way for us to determine effectiveness. But, let’s just let the laymen determine what the doses should be. Titrating an insulin dose is much easier because objective measurements could be used to determine proper therapy. It cannot be done with pain, since it has no objective determination.

  9. Parking a line of woodchippers in front of the CDC sounds like a good idea right about now.

    1. Not a good idea. We have only ourselves to blame for letting the 12 Step cults grow out of control.

    2. I’ll help.

  10. This stupid bullshit that pain medication is turning junkies into everyone was taken to the absurd in season one of Ozark, a Netflix show starring Jason Bateman. Not to spoil too much, and the episode itself shows events in non-chronological order for I suppose, dramatic reasons. But a woman who takes a pain pill after being urged by her son, who is unhappy seeing her in distress, is shown much later sneaking into shady houses to shoot up heroin. It was so farcical, I laughed. Unfortunately, some people seem to really believe this shit.

  11. “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.”

    “You’re feeling better now, right? RIGHT?!”

    1. Yeah, I love that whole “counseling” thing. Seems to me that, when someone has arbitrarily decreed that you have to be in greater — possibly crippling — pain because “reasons,” anxiety is actually a pretty damn rational response.

  12. This is cruel! We need single payer to put an end to this!

    1. Single payer would not contribute one damned thing to the situation! It has nothing to do with cost, and everything to do with control of the patients, allowing them to suffer in pain! that is insane!

  13. Alcohol,cocaine,heroin and marijuana had no restrictions between the Civil War and WW1, when USA was a leading source of inventions and industry.

  14. I’m confused.

    So now Reason.com is arguing in favor of gov’t social programs?

    1. No, you fucking moron, reason.com is arguing against the government telling you what the maximum pain medication dose you can take is.

      Go throw yourself into a running woodchipper feet first, fucking slaver. You’d make better mulch than you do a man.

      1. You seem confused.

        That’s not what this article or the policy says.

        It says they will simply limit how much they pay for.

        But obviously you are too goddam stupid to know that.

  15. ” against the advice of critics who say that move will lead to needless suffering. Those critics include doctors who helped produce the guidelines.”

    So they enlisted in the War On Drugs and are now shocked at the unintended consequences. Hey, it’s a fucking war. There’s always collateral damage.

  16. Top grade marijuana,Edibles,Wax oils and Pain relief pills

    Top legit and genuine suppliers of Best medical marijuana

    like,Cannabis,
    sour diesel etc at affordable prices available. Very good for

    patients of
    cancer of all kinds.We await good customers.

    E-mail Address; (bodybuildingpharma59@gmail.com)
    Text or Call; (325) 261-0302

    *Grand Daddy Purple Grade: A
    *Sensi Star x ak47 Grade: AAA
    *Northern Lights #5 :Grade: A+
    *Lemon KUSH:Grade: A+
    *Purple Kush:Grade:A+ Top Shelf
    *OG Kush :Grade:A++ Top
    *purple-urkle:Grade:A+
    *White Widow:A+
    *Blue Dream:A++
    *kurupts moonrock: A+
    *Kratom:A
    *Edibles
    *Wax oils

    And more….

    we are also suppliers of pain anxiety pain relief meds. Discount

    are also
    applicable for bulk buyers.The shipping is meticulously planned;

    packaging
    is done. Such as

    ,Adderall,Ativan,Oxycontin,Xanax,percocets,Morphin and
    more…
    E-mail Address; (bodybuildingpharma59@gmail.com)
    Text or Call; (325) 261-0302

  17. We are top suppliers Marijuana, pain pills, sex pills and anxiety meds available (we have meds like xanax, tramadol, percs, oxy, roxy, valium, actavis syrup, etc… +1 (724) 470-0553. Call: +1 (419) 299-6124
    Email Us Via : discreetsales2015(@)gmail.com

  18. We are medicine suppliers (without Prescription) Base in USA & South Africa providing a convenient way for drugs without prescription to get to your door. We also provide a better channel for legal or non-legal cannabis patients to receive their medication without leaving their home or office. Be treated like a VIP!
    We are a trusted middle-man a drop shipper and suppliers of a wide range of Pharmaceutical Formulations specializing in Pain Killers, Anti Anxiety, Weight loss, Steroids, Marijuana HGH, ADHD & ED , Research Chemicals + more that 100 different medicines. These are sourced from reliable vendors that make sure that our product range is safe.

    CONTACT US
    Be treated like a VIP! +1 (724) 470-0553
    WhatsApp # only: + 15753835081
    S.A OFFICE
    Whatsapp Number: 0027642338548 / Call Tel: 0027642338548

  19. We are medicine suppliers (without Prescription) Base in USA & South Africa providing a convenient way for drugs without prescription to get to your door. We also provide a better channel for legal or non-legal cannabis patients to receive their medication without leaving their home or office. Be treated like a VIP!
    We are a trusted middle-man a drop shipper and suppliers of a wide range of Pharmaceutical Formulations specializing in Pain Killers, Anti Anxiety, Weight loss, Steroids, Marijuana HGH, ADHD & ED , Research Chemicals + more that 100 different medicines. These are sourced from reliable vendors that make sure that our product range is safe.

    CONTACT US
    Be treated like a VIP! +1 (724) 470-0553
    WhatsApp # only: + 15753835081
    S.A OFFICE
    Whatsapp Number: 0027642338548 / Call Tel: 0027642338548

Please to post comments

Comments are closed.