Federal Panel Urges Incentives to Prescribe Opioid Alternatives

Alicia Ault

November 01, 2017

In its final report, the President's Commission on Combating Drug Addiction and the Opioid Crisis, led by Governor Chris Christie, is calling for new federal policies that would remove pain as a vital sign and calls for incentives that steer prescribers toward nonopioid and nonpharmacologic alternatives. 

The Commission recommended that the Centers for Medicare and Medicaid Services (CMS) remove pain survey questions from patient satisfaction surveys, "so that providers are never incentivized for offering opioids to raise their survey score." Hospitals should also be prohibited from using patient ratings from such surveys improperly.

The Commission also recommended broader access to medication-assisted treatment, better reimbursement for outpatient and inpatient psychiatric and substance use disorder care, and a new public education campaign to prevent addiction and remove stigma.

Established in March, the Commission met a total of five times. Recommendations from its interim report in July were incorporated into the final report, issued on November 1.

A key earlier recommendation was that President Donald J. Trump declare the opioid crisis a national emergency. Trump stopped short of that, but did declare a public health emergency on October 26.

Christie said on November 1 that he had specifically asked for a public health designation — not national emergency — so that the US Department of Health and Human Services (HHS), and not the Federal Emergency Management Agency, would manage funding for the opioid response.

Equivalent to a Terrorist Attack

The declaration did not establish any new funding for the opioid epidemic, and the Commission's final report does not make any specific requests.

In a letter accompanying the final report, Christie noted that "it is not the Commission's charge to quantify the amount of these resources, so we do not do so in this report."  

However, the chairman made it clear that the Commission expected Congress to respond and that it should "happen without delay."

Congress "must step up and work with [the president] to appropriate the funds in the Public Health Emergency Fund and in other places that we suggest in this report to be able to do what needs to be done," Christie said.

He added that the Commission would make it clear to Congress that the opioid epidemic was equivalent to a war.

"If a terrorist organization was killing 175 Americans every day on American soil, what would you be willing to pay to make it stop," he said. "I'd think we'd be willing to do everything and anything to make it stop, and that's the way we now need to see this," said Christie.

Commission member and former congressman Patrick Kennedy said he estimated that at least $10 billion a year was needed, noting that the nation had spent some $24 billion a year on the AIDS epidemic, which killed some 53,000 Americans each year — on par with the 60,000 dying from drug overdoses annually.

"There's no reason why we can't expect a similar amount of dollars being spent," Kennedy said.

After the report's release, Chuck Ingoglia, senior vice president for public policy and practice improvement at the National Council for Behavioral Health, said in a statement that while the organization, which represents 2900 mental health services providers, agreed with many of the Commission's recommendations, it was still disappointed that it had not urged any specific funding.

"In addition to no increased federal spending, the report does not recommend expanding the Excellence in Mental Health and Addiction Act, which would allow more Americans to access comprehensive, coordinated treatment services," Ingoglia said.

In addition, the Commission's suggestion that the federal government issue block grants for addiction treatment "may ease some regulations but does nothing toward combatting the opioid epidemic," he said.

Christie said the Commission "identified a disturbing trend in federal health care reimbursement policies that incentivizes the wide-spread prescribing of opioids and limits access to other non-addictive treatments for pain, as well as addiction treatment and medication-assisted treatment."

The panel urged a change. "We should incentivize insurers and the government to pay for non-opioid treatments for pain beginning right in the operating room and at every treatment step along the way," said Christie.

The Commission recommended that the Centers for Medicare and Medicaid Services review and modify policies that discourage the use of nonopioid treatments for pain, such as bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors.

The American Medical Association (AMA) has already endorsed this idea.

After President Trump's emergency declaration, Patrice A. Harris, MD, MA, chair of the AMA's Opioid Task Force and Immediate Past Chair of the AMA, said in a statement that " as physicians, we must be leaders in continuing to make judicious prescribing decisions, and by considering the full range of effective therapies for pain, including non-opioid and non-pharmacologic options, co-prescribing naloxone, helping patients access medication-assisted treatment for opioid use disorder and removing stigma."

"At the same time, insurers must be willing to cover pain treatments beyond opioid analgesics as well as long-term comprehensive treatment for opioid use disorder to promote recovery," Dr Harris added.

The Commission also recommended an expansion of treatment availability and that the federal government change its policies to more truly reflect the cost of treating substance use disorders.

Expansion is already under way at CMS, which said, the same day as the report was issued, that it was granting waivers from restrictive Medicaid treatment rules to Utah and New Jersey.

The Commission also urged HHS to review and modify its rate-setting to better cover the true costs of providing substance use disorder treatment, including inpatient psychiatric facilities and outpatient providers. It also urged the government to expand its ability to penalize insurers for mental health parity violations.

It called on federal agencies to remove barriers to treatment, such as limits on access to medication-assisted treatment (MAT), counseling, and inpatient/residential treatment.

New Rules

Several recommendations will likely affect prescribers. These include:

  • Government agencies should develop model statutes, regulations, and policies that ensure informed patient consent — understanding the risks and benefits, and alternatives — prior to an opioid prescription for chronic pain

  • HHS should help develop a national curriculum and standard of care for opioid prescribers

  • Federal agencies should work to collect data on prescribing patterns and match it with participation in continuing medical education (CME) to determine program effectiveness

  • The Administration should develop a model training program for all prescribers on screening for substance use and mental health status to identify at-risk patients

  • The Administration should work with Congress to amend the Controlled Substances Act to allow the Drug Enforcement Administration (DEA) to require that all prescribers show participation in an approved CME program on opioid prescribing before getting their DEA license renewed

  • Federal agencies and pharmacy associations should train pharmacists on best practices to evaluate legitimacy of opioid prescriptions, and not penalize pharmacists for denying inappropriate prescriptions

The Commission also recommended using MAT in prisons and jails and that the US Department of Justice establish federal drug courts within the federal district court system in all 93 federal judicial districts. People with a substance use disorder who violate probation terms because of substance use should be diverted into a drug court, not prison, said the Commission.

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