Medicare Agency Retreats From Arbitrary Limit on Pain Medication

Under the final rule, pharmacists may fill high-dose opioid prescriptions as long as they verify them.


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The Centers for Medicare and Medicaid Services (CMS) has retreated from a proposed rule that would have forced many patients to choose between living in agony and shelling out thousands of dollars more every year for pain medication.

Under the original proposal, Medicare generally would not have covered prescriptions for 90 or more morphine milligram equivalents (MMEs) per day. While there were exceptions for cancer and hospice patients, other Medicare beneficiaries suffering from severe chronic pain would have been out of luck unless their doctors mounted successful bureaucratic appeals. CMS reported that 1.6 million Medicare patients received daily opioid doses of 90 MME or more in 2016.

Not surprisingly, the 90-MME cap provoked strong objections from patients and doctors. "The 90 MME hard edit guidance was strongly opposed by nearly all stakeholder groups for a variety of reasons," CMS reported last week. "Physician groups opposed the forcible/non-consensual dose reductions due to the risks for patients of abrupt discontinuation and rapid taper of high dose opioid use. Similarly, we received hundreds of letters from patients who have taken opioids for long periods of time and are afraid of being forced to abruptly reduce or discontinue their medication regimens with sometimes extremely adverse outcomes, including depression, loss of function, quality of life, and suicide." Furthermore, "the overall consensus was that a 90 MME-per-day hard edit threshold would have little clinical impact against opioid overuse."

The final policy adopted by CMS instead requires a pharmacist who receives a prescription above the threshold to confirm it with the doctor and document the discussion. Stefan Kertesz, the University of Alabama at Birmingham internist who organized a letter in which hundreds of physicians objected to the original plan, told The Hill the revised policy is "humane and reasonable."

The 90-MME cutoff was copied from the supposedly nonmandatory opioid prescribing guidelines issued by the Centers for Disease Controll and Prevention in 2016. The CDC said doctors "should avoid increasing dosage" above 90 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.

Given that experience, it is hard to believe the CMS did not anticipate the backlash that its "hard edit guidance" would generate. Like the CDC, it seems to be pursuing the mission of reducing opioid abuse with little thought of the consequences for innocent bystanders.

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  1. You mean to say government employees don’t know what’s best for you?

  2. Oh yay, government is going to overpay for more artificially expensive opiates and allow people not even to have to work for it. Thanks for exposing another injustice, Reason!

    1. Also thanks for conflating ‘refuse to prescribe’ and ‘refuse to reimburse’. Why confuse your readers unnecessarily?

      (And while you’re at it, why not ban anyone who points out the difference?)

    2. This is not just Medicaid patients, it’s Medicare as well, hence millions of people who DID in fact work for the benefits they are receiving! Second, this includes millions who are NOT addicts suffering from unbearable pain thanks to medication cuts over worries about addiction and overdosing which more often than not is because addicts mix prescription drugs with street drugs, alcohol, etc. Veterans who fought for our country and have severe pain from injuries are suffering and killing themselves, as are people who were once healthy and hard working who have sustained injuries through no fault of their own. Hope you never have to know what its like to live in agony that only pain meds can help after trying EVERY other non pharmaceutical treatment available….oh wait, yes I do, because I bet you’d change your tune and vile comments! Go f@#% yourself! Better yet, I hope karma bites you in the ass – then I hope you remember this callous comment. There is no doubt opiates need to be prescribed more judiciously, but people in pain do not get high and should not have to suffer or kill themselves because of addicts!

  3. I’m commenting on Hit & Run in order to buy sex.

    Anybody got a problem with that? I’m asking you, FOSTA/SESTA!

  4. Ok, people: I expect some progress here, because, unlike practically every other do-gooder concern to be had, I do plan on actually dying one day. And I want to go out with the warm fuzzies of opioids running through my veins.

    I really don’t want to die somewhere between serious discomfort and complete agony just because the FDA and some such is hand-wringing that I might get addicted to heroin after I’m cremated.

    Cut this shit out, bitches.

  5. nearly three out of four people who died of an overdose had been on Medicaid at some point in the year before they died

    In case there are any libertarians left out there, this is evidence showing how medicaid/medicare opiate prescriptions kill. What’s going on here? Free pills can be lethal. Better to let people pay for it above a certain dosage and time. And guess what? If they need it, they will! Welcome to the free market!

  6. So here’s something to chew on. I was diagnosed a little over a year ago with Arachnoiditis, a rare disease that causes non stop horrific pain in my back. It also affects the central nervous system so I also expirence joint pain, headaches, blurred vision, weight gain, my teeth crack and fall out, swelling of my limbs, vomiting, diffulcty urinating, constipation just to name a few. The only doctor that treated this was forced to retire by the DEA because he actually prescribed the appropriate amount of opioid pain medication to his patients. Now his 150ish patients are left without a doctor and the terrifying reality that we may not find someone to help us and that isn’t afraid of the damn government restrictions. I take a lot of medication that isn’t an opioid and I also take a few that are. For one of my pain meds that is injectable that I can only get at one place in the entire country I pay $730 every 23 days. I have developed some strange absorption issue, so I can tolerate a much higher dose than your average Joe.
    This means that the crazy high dose I take hardly dulls the pain. What do I do??? Come on America, we need your help. Please.
    (Please forgive any spelling/grammar errors)

  7. Cont.
    I know it’s not reasonable to continue upping my dosage and I don’t have insurance nor have I received my Medicare yet because I haven’t been disabled long enough and I don’t have cancer. I was actually told by a Social Security rep that I’d need to have cancer to get my benifits early. Really?!?! No wonder some people give up on the system and commit suicide. How many deaths does the DEA and the Government need to be responsible for before this STOPS???

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