Medicare Planning to Adopt CDC Opioid Guidelines

Medicare Planning to Adopt CDC Opioid Guidelines — Pain News Network – February 03, 2017 – By Pat Anson, Editor

The Centers for Medicare and Medicaid Services (CMS) has announced plans to fully implement the opioid prescribing guidelines released by the Centers for Disease Control and Prevention, which recommend that doctors not prescribe opioid medication for chronic non-cancer pain.

CMS is taking the CDC’s voluntary guidelines one step further, however, by mandating them as official Medicare policy and taking punitive action against doctors and patients who don’t follow them.

As Pain News Network has reported, CMS is adopting a “Big Brother” approach to fighting opioid abuse by developing a strategy that will encourage pharmacists to report doctors who may be overprescribing opioids and patients who may be abusing them.   

Information about these “potential opioid overutilizers” would be shared with insurance companies, which would be empowered to “prevent opioid overuse at point of sale at the pharmacy.”

“To address the opioid epidemic, CMS has implemented a medication safety approach by which sponsors are expected to reduce beneficiary overutilization of opioids and maintain access to needed medications,” the agency said in a statement.

The perpetual question is how to define “overutilization” when there is such extreme variability in individuals’ responses, both in their metabolism and the efficacy of these drugs.

Instead of letting our doctors decide how much medication we need according to our individual symptoms and bodies, uninvolved, impersonal, non-medical outsiders want to determine our medical needs:

  • the addiction recovery industry,
  • government agencies, and
  • the insurance industry.

Saying it wanted to “better align” its policies with the CDC guidelines, CMS is proposing a daily ceiling on prescribed opioids at 90 mg morphine equivalent dose (MED).

Any dosage above that level would be considered excessive.

Patients who receive opioids from more than 3 prescribers and more than 3 pharmacies during a 6 month period would also be red-flagged.

Insurers would be expected to police pharmacies, doctors and patients who do not follow CMS policies, potentially dropping them from Medicare coverage and their insurance networks.

When insurers who have not examined or spoken to me determine my medical treatment, does this not qualify as “practicing medicine without a license”?

Perhaps we should present ourselves to our insurers instead of our doctors since they are the ones with the power to decide our treatment now.

Of all the entities now exerting control over our medical care, only our own doctors know enough about us and our situation to determine what and how much medication we need.

Under the Part D opioid overutilization policy, sponsors are expected to implement appropriate plan-level claim controls at POS (point of sale) for opioids, use improved retrospective drug utilization review to identify beneficiaries at high risk for an adverse event due to opioids, and perform case management with the identified beneficiaries’ prescribers followed by beneficiary-specific POS edits to

Critics of the CMS strategy say it is even more draconian than the CDC guidelines, which are intended only for primary care physicians.

“CDC’s ‘soft limit’ of 90 MED in treating chronic pain was a recommendation aimed at treatment of some people with chronic pain by primary care specialists. CDC stated that all of its recommendations were voluntary, and in this case, further provided prescribers with the option to use a higher dose if indicated by a careful risk/benefit analysis,” Twillman said in an email to PNN.

Strategy Developed by Insurance Industry

The agency’s proposed “Opioid Misuse Strategy” was released publicly in early January.  It closely follows a 62-page “white paper” prepared by the Healthcare Fraud Prevention Partnership (HFPP), a coalition of private insurers, law enforcement agencies, and federal and state regulators formed in 2013 to combat healthcare fraud.

The white paper, however, goes far beyond fraud prevention by recommending policies that will determine how a patient is treated by their doctor, including what medications should be prescribed.

The number of Medicare patients who “overutilize” opioids is relatively small – just 15,651 beneficiaries in 2015 – which represents just 0.13% of Part D opioid users.

CMS is seeking public comment on the proposal in its 2018 Advance Notice and Draft Call Letter, which outlines a number of other changes the agency is making to its Medicare Advantage and Part D prescription drug programs.

Comments will be accepted through March 3rd, with final versions published on April 3, 2017.

Comments can be emailed to:


6 thoughts on “Medicare Planning to Adopt CDC Opioid Guidelines

  1. Val Branch

    Wow, wow, wow, cannot believe that the insurers will dictate to physicians about what and how much pain medication they can prescribe. It is hard to believe that it has come down to policing chronic pain patients because of opioid deaths by people who should not have had them to begin with. I have been with the same pain management doctor for over 10 years and have been redflagged because of this and had my prescription for delayed for a week and still waiting. Should be great for making people who are dependent on medication to go into withdrawal. Big Brother KNOWS BEST!

    Liked by 1 person

    1. Zyp Czyk Post author

      Of course, none of this is preventing heroin overdoses, which just keep climbing.

      Pretty clever of the anti-opioid folks to lump together pain meds with heroin to create this misguided government control over our medication.


    2. Zyp Czyk Post author

      They believe they are saving us from turning into addicts, switching to heroin, and then overdosing. They believe they’re doing it all for our own good. They believe that as strongly as we believe we need opioids.

      What can anyone do about that?


  2. Kelli

    This is ridiculous! Prescription opiates are not the issue. New studies show that even though there has been a distinct decline in opioid prescriptions, the overdose rate continues to rise. This is because people are over dosing on heroin and carfentynal! Not prescribed medications! I am appalled that the government, which has no right to dictate medical needs, is getting more involved in this blatant abuse of chronic, intractable pain patients. We ate not the cause of the issue at hand. The government needs to focus their efforts where it will make a difference. The streets and our borders. Get the illegal drugs off the street and prevent more from coming in at the border. Until those 2 things are done, thesee agencies need to leave the medical profession and it’s patients alone!

    Liked by 1 person

    1. Zyp Czyk Post author

      Unfortunately, the government has latched onto this “opioid crisis” as part of the never-ending “war on drugs”, so I doubt things will be getting better any time soon.

      They still believe a drug-free country, and even a drug-free world, is possible – and desirable. I guess they don’t know much about history, because humans have indulged in mknd-altering substances for millennia – even animals seek out overripe berries for their alcohol content.



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