William Haning, MD, DFASAM, DFAPA
Two weeks ago, Jan Hoffman in the New York Times reported on an impending CMS rule that proposed to tightly constrain prescribing of opioids. The article described patients’ and providers’ concerns regarding the limitations. Implicit in the rule change were three expected outcomes: 1) reduction in Medicare part D costs; 2) a reduction in the pool of opioids available for diversion; 3) improvement in adherence to best prescribing practices. Difficulties which immediately became evident upon review of the pertinent section within the 231 page proposal included the likelihood that benefits administrators would use the rule to impose onerous pre-authorization requirements upon prescribers: providers already burdened with managing chronic pain disorders. Further concerns included the experience of patients considering committing suicide, as well as those actually having done so, in the anticipation of abrupt medication withdrawal. While the rule limits appeared to conform to the CDC’s 2016 guideline for opioid prescribing, they diverged in one salient respect: transformation of a recommendation to a Federal expectation. In the course of reviewing the assumptions made by the proposed rule, we find studies arguing against the assumption that physician prescribing patterns for chronic pain provide the major source of opioids for misuse. Recent congressional testimony by Dr. Debra Houry of the CDC indicates that prescriptive diversion is diminishing in importance as a source of overdose deaths. Dr. Stefan Kertesz, Professor and clinician at the University of Alabama and rightly well-recognized as a patient advocate, submitted a written opinion to CMS with over 220 signatories, including from within addiction medicine, in opposition to the proposed rule. His arguments are lucid and compelling. As of this week, in response to commentary, CMS modified the proposed rule substantially. CMS’s response to advice and feedback warrants appreciative acknowledgment.
Footnote: Both the intended rule, and the responsive commentary by professionals such as Kertesz and by patients, demonstrate the complexity confronted in any effort to control prescribing practices by fiat. This week, at the ASAM scientific conference, Oxford University Press will release the first edition of the American Society of Addiction Medicine Handbook on Pain and Addiction, the Society’s publication effort to address this complexity, and to supplement the conference’s annual course on pain and addiction.
Since the source of opioids used in overdoses is moving away from prescription medications and more to black market/street purchases, why penalize physicians who are already over-burdened with prior authorizations and everything else that adds to the administrative burden we face?