Finally! I’m still outraged that the AMA stood by silently for 5 long years as more and more pain patients were deprived of legitimate medical opioid treatment.
They remained silent as law enforcement second-guessed doctors’ decisions and essentially dictated our treatment. I didn’t hear a peep of protest when appropriate medical care was decided by the DEA and enforced by SWAT teams.
So pardon me if I’m not giving the AMA adulation or kudos or praise for doing what they should have done 5 years ago. Their inaction led directly to the suicides of so many pain patients who were deprived of pain relief on the basis of these appallingly arbitrary and misapplied CDC guidelines.
The American Medical Association (AMA) is urging the Centers for Disease Control and Prevention (CDC) to make significant revisions to its 2016 Guideline for Prescribing Opioids for Chronic Pain.
Among its recommendations, the AMA called for CDC to remove arbitrary limits or other restrictions on opioid prescribing given the lack of evidence that these limits have improved outcomes for patients with pain.
Rather, they have increased stigma for patients with pain and have resulted in legitimate pain care being denied to patients.
“Hard thresholds should never be used. Where such thresholds have been implemented based on the previous CDC Guideline, they should be eliminated,” Dr. Madara wrote.
Excerpts from full letter of AMA Opioid Comments:
To make meaningful progress towards ending this epidemic, a broad-based public health approach is required. This approach must balance patients’ needs for comprehensive pain management services, including access to non-opioid pain care as well as opioid analgesics when clinically appropriate, with efforts to promote appropriate prescribing, reduce diversion and misuse, promote an understanding that substance use disorders are chronic conditions that respond well to evidence-based treatment, and expand access to treatment for individuals with substance use disorders.
The nation no longer has a prescription opioid-driven epidemic.
However, we are now facing an unprecedented, multi-factorial and much more dangerous overdose and drug epidemic driven by heroin and illicitly manufactured fentanyl, fentanyl analogs, and stimulants.
We can no longer afford to view increasing drug-related mortality through a prescription opioid-myopic lens.
The nation’s opioid epidemic has never been just about prescription opioids, and we encourage CDC to take a broader view of how to help ensure patients have access to evidencebased comprehensive care that includes multidisciplinary, multimodal pain care options
the AMA urges CDC to work with physicians and patients to ensure that the revisions support patients with pain and the physicians who care for them.
AMA Pain Care Task Force (PCTF) was formed in 2018. The newly formed PCTF is made up of representatives from 20 health care associations. This broad-based group of clinicians and experts is working collaboratively to improve pain care for patients by identifying actionable opportunities to improve medical education related to pain care
has developed Principles of Care for Evidence-based Pain Management, as well as outlined systemic barriers and potential solutions in the delivery of pain care in the United States in an upcoming article in the AMA Journal of Ethics
In many cases, health insurance plans and pharmacy benefit managers have used the 2016 CDC Guidelines to
- justify inappropriate one-size-fits-all restrictions on opioid analgesics while also
- maintaining restricted access to other therapies for pain.
There is no question that the nation’s physicians have reduced opioid analgesic supply—both in volume and dose strength—but there has not been a concomitant increase in access to or affordability of evidence-based non-opioid alternatives.
The Task Forces further affirm that some patients with acute or chronic pain can benefit from taking prescription opioid analgesics at doses that may be greater than guidelines or thresholds put forward by federal agencies, health insurance plans, pharmacy chains, pharmacy benefit management companies, and other advisory or regulatory bodies.
The Task Force continues to urge physicians to make judicious and informed prescribing decisions to reduce the risk of opioid-related harms, but acknowledges that for some patients, opioid therapy, including when prescribed at doses greater than recommended by such entities, may be medically necessary and appropriate.
The AMA urges the CDC Guideline start by recognizing the need for individualized care for patients with pain.
As a starting point, the AMA points to the well-received recommendation from the U.S. Health and Human Services Pain Management Best Practices Interagency Task Force 7 that patients experiencing pain need to be treated as individuals, not according to one-size-fits-all algorithms and policies that do not take individual patient’s needs into account.
Yet, the CDC Guideline also included multiple arbitrary dosage and quantity recommendations that have been consistently misapplied by state legislatures, national pharmacy chains, pharmacy benefit management companies, health insurance companies, and federal agencies.
Early on, the AMA feared that the arbitrary opioid analgesic dosage and quantity thresholds appearing in the CDC Guideline would cause unintended consequences when used to severely limit individual treatment decisions made by physicians.
The CDC Guideline has harmed patients
It is clear that the CDC Guideline has harmed many patients —so much so that in 2019, the CDC autho rs 11 and HHS issued long-overdue, but greatly appreciated, clarifications that states should not use the CDC Guideline to implement an arbitrary threshold
In addition, we also ask that CDC include patient advocates in its formal review of these and other comments as part of any revision to the CDC Guideline to ensure that patient needs are adequately addressed
Although population-level data may be relied on to help construct clinical guidance…
pain is an intensely personal and conscious experience influenced by emotion, cognition, memory, interpersonal, racial and social context, and other factors.
Patient-reported intensity of pain may not correlate with the magnitude or identifiable source of injury.
It’s incredible to me how many medical professionals still don’t know this and assume that if a cause for pain cannot be found, then the patient must just be imagining it.
Accepting a patient’s complaint of pain as valid does not require clinical identification of a physical cause or demand the initiation of a specific treatment.
The CDC Guideline has been misapplied as a hard policy threshold by states, health plans, pharmacy chains, and PBMs
Examples of inappropriate policies with specific limits or policies that misapply the CDC Guideline in different ways and have resulted in specific harm to patients include the following:
- Walmart’s policy includes a 50MME or 7-day hard threshold for opioid prescribing;
- CVS Caremark’s policy has multiple restrictions, including a 7-day hard threshold for opioid prescribing;
- OptumRx’s policy is aligned with 2016 Guidelines
- Walgreen’s Good Faith Dispensing Policy does not list specific thresholds, but the AMA has received numerous complaints about pharmacists refusing to fill a prescription because of “corporate policy.”
- Blue Cross-Blue Shield Association 7-day hard threshold;
- United Healthcare 7-day, 90 MME hard threshold; and
- More than 30 states have enacted laws with opioid prescribing restrictions ranging from 3 to 14 days, including many with MME limits and other restrictions.
You can read about the specific policies from these references:
“Walgreens Q & A Prepared for the New Hampshire Medical Society” https://www.nhms.org/sites/default/files/Pdfs/proofed%20walgreens%20policy%206-5-2013.pdf.
ADDRESSING THE OPIOID CRISIS: Preventing Abuse and Ensuring Patients Receive the Right Care in the Right Setting. Blue Cross Blue Shield Association. September 2018. https://www.bcbs.com/sites/default/files/file-attachments/page/Opioids%20Whitepaper.pdf.
2020 Opioid Readiness: UnitedHealthcare Medicare Advantage and Prescription Drug Plans Quick Reference Guide. United Healthcare. https://www.uhcprovider.com/content/dam/provider/docs/public/resources/pharmacy/opioids/Provider-opioid-qrg-2020.pdf.
Prescribing Policies: States Confront Opioid Overdose Epidemic. National Conference of State Legislatures. June 30, 2019. Available at https://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx.
Second Annual Survey of Pain Medicine Specialists Highlights Continued Plight of Patients with Pain, and Barriers to Providing Multidisciplinary, Non-Opioid Care. American Board of Pain Medicine. Available at http://abpm.org/uploads/files/abpm%20survey%202019-v3.pdf.
there is evidence that payers continue to erect and support barriers to non-opioid pain care.
A 2019 survey from the American Board of Pain Medicine 19 found:
- 72 percent of pain medicine specialists said that they—or their patients—have been required to reduce the quantity or dose of medication they have prescribed;
- 92 percent of pain medicine specialists said that they have been required to submit a prior authorization for non-opioid pain care—with the physicians and their staff spending hours per day on such requests; and
- 66 percent of pain medicine specialists said that they have had to hire additional staff to handle the prior authorization requirements.
Read the full AMA letter and each recommendation to revise the CDC guideline.
Tomorrow, I’ll post excerpts and my comments on the specific changes the AMA is finally requesting (which they should have done after seeing the first draft of this abomination).
I suppose it’s better late than never… except for the suicides caused by these pain relief restrictions that PROP convinced the CDC to publish.