An Opioid Quality Metric Based on Dose Alone? 80 Professionals Respond to NCQA by Dr. Stefan Kertesz
Efforts to reduce prescribing while optimizing care for patients with pain, and expanding access to addiction treatment, are of cardinal importance.
How we advance these objectives depends partly on changing our shared understandings of what it means to deliver good care. It also depends on policies, resources and formal methods to assess if we are doing a good job.
Dr. Kertesz points out that all these new restrictions aren’t based on any studies at all. Nor are any studies planned to investigate the effect of these new policies.
The 2016 Guideline on Prescribing Opioids for Chronic Pain from the Centers for Disease Control and Prevention (CDC) represents one such effort.
In early 2017, a new and consequential proposal was made by the National Committee for Quality Assurance (NCQA), which seeks to advance health care quality through measurement and accreditation. NCQA’s highly influential performance measures help purchasers and consumers to assess whether health care quality is good or bad. When NCQA issued a draft set of standards related to opioids in 2017, they requested public comment. [see Another Committee Setting New Rules for Opioids]
One of the measures counts the percentage of health plan members receiving opioid doses greater than the equivalent of 120 milligrams of morphine (MME), with a lower percentage counting as evidence of better care.
The premise, focused on dose, is similar to recent proposal from the Centers for Medicare and Medicaid Services.
The concern about dose as an important risk factor for adverse opioid outcomes is well-justified. But well-justified concerns do not always translate into fault-free performance targets, particularly when doing so entails clinical practices not yet tested in scientific trials, and not endorsed by the CDC Guideline.
Eighty doctoral level clinicians from across the country, mostly academic physicians, have endorsed the letter submitted to NCQA on March 22, 2017.
They include four who had roles assisting the Centers for Disease Control and Prevention in development of the 2016 CDC Guideline, and five who edit scholarly journals in addiction medicine or pain.
We write to register strong objection to the proposed “Opioid High Dosage” HEDIS measure, focused on minimizing the number patients receiving greater than 120 morphine milligram equivalents.
As doctoral-level professionals in pain, in medicine and allied fields, we believe this measure will incentivize care that violates principles in the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.
As a result, it will pose a serious risk to some patients currently receiving opioids.
Many signatories to this letter have expertise in addiction medicine or pain medicine.
Many of us play professional roles in helping patients at high doses to taper, in mitigating opioid risk, in minimizing new opioid starts and in restraining dose escalation.
Given these commitments, we understand that our strong objection to the proposed NCQA measure may come as a surprise.
To explain this objection, we must distinguish between the language of the CDC Guideline itself, and the perverse care decisions that the NCQA “Opioid High Dosage” binary measure will incentivize.
The CDC Guideline cites observational evidence associating higher opioid doses with increased adverse outcomes, including overdose. Such data justify restraint in opioid initiation (Recommendation 1) and dose escalation
However, the CDC Guideline did not prohibit dose escalation. Nor did it propose that any dose above a numeric threshold was “bad care”. Rather it insisted on “individual assessment of risk and benefit” as the primary basis for decision making related to both opioid dose titration and opioid dose reduction
On this basis, most of us wish to see an evolution toward fewer opioid starts and fewer patients at high doses. The proposed NCQA measure indulges no such subtleties. It will incentivize rapid efforts to minimize the number of patients whose current opioid dose exceeds 120 MME.
The most efficient action to optimize measure performance would involve dose reduction for patients at >120 MME, regardless of
- patient acceptance,
- the mix of benefits and harms specific to the individual patient, or
- the potential harms of rapidly tapering patients prescribed high doses for many years.
This is happening in many health systems today, despite the lack of any evidence to assess its impact on risk to patients, and the reality that the CDC Guideline did not endorse this approach.
Of particular concern, widespread unilateral dose reductions that would be incentivized by this HEDIS measure contradict Recommendations 5 and 7 of the CDC Guideline, both of which emphasize individualized assessment and decision making
High dose is cited as simply one indicator of risk in the discussion of tapering. The proposed “Opioid High Dosage” measure eviscerates the CDC Guideline of these patient-centered considerations
Put simply, the “Opioid High Dosage” measure will accelerate a reconfiguration of care that has never been tested in prospective trials and that could actually increase risk to individual patients, as illustrated by
- scholarly and popular reports of acute withdrawal (with death),
- protracted abstinence syndrome, and
associated with incautious unilateral opioid discontinuation or unrelenting pain.
Finally we must underscore that institutional embrace of binary quality measures based on promising epidemiologic data has sometimes proven a mistake in retrospect
We urge NCQA to recognize that binary metrics developed in the absence of compelling controlled trials are often treacherous. And there is little to justify a HEDIS measure that contradicts the language found in CDC Guideline Recommendations 5 and 7.
- 4 who had formal roles assisting the Centers for Disease Control and Prevention in development of the 2016 CDC Guideline.
- 5 who edit scholarly journals in addiction medicine or pain,
- 60 with academic affiliations,
- 33 with special expertise in addictions, and
- 23 with special expertise in pain.
These are true experts in opioid prescribing, so their opinions are based on real facts of medical practice, presented by real patients and their real responses.
This opinion is actually fact-based, which is extremely rare these days in any discussion of opioids.