The Pendulum Has Swung Too Far

Treating Pain in Primary Care

Linda Brookes, MSc


February 22, 2019

In This Article

Physicians on the Firing Line

Doctors who prescribe opioids—especially to the elderly, who may die of health causes—can find their practices under investigation by government agencies or state medical boards. The atmosphere around prescribing for chronic pain has been described as so fraught that many clinicians feel they must avoid prescribing opioids completely. In some cases, this has even led to tapering patients off their medications without patient consent. Other clinicians may decide to no longer accept patients with a history of needing high-dose opioids.

"We are all uncomfortable about the legal risk of prescribing these drugs," Hsu admits. "In my own practice, we see many pharmacies not stocking opioids or limiting supplies, so that patients will often have to go to multiple pharmacies in an effort to find these medications.

It's a no-brainer that there is probably a substantial impact that is occurring.

"I don't like the government getting involved in trying to regulate my ability to use my prescribing capabilities," Vega complained. "I think they are better off educating and weeding out those that are problematic and letting those of us who are not problematic do what we need to do."

In April 2018, FDA Commissioner Gottlieb emphasized the need to implement "new policies that rationalize prescribing, and set a new and more appropriate medical standard for the use of opioids." The SUPPORT for Patients and Communities Act, signed into law in October 2018, requires that the Department of Health and Human Services study and report to Congress on the impact of federal and state laws and regulations that limit the length, quantity, or dosage of opioid prescriptions. "We need studies to determine the impact of these policy initiatives and move away from anecdotes," Reid said. "It's a no-brainer that there is probably a substantial impact that is occurring."

Medicare Gets Into the Act: New Prescribing Restrictions

Additional restrictions to prescribing opioids in older patients went into effect January 1, 2019, with new "overutilization policies" introduced by the Centers for Medicare & Medicaid Services (CMS) affecting Medicare Part D beneficiaries. New prescriptions are now limited to a 7-day supply. If a Medicare patient presents an opioid prescription at the pharmacy and their cumulative MME per day across all their opioid prescriptions reaches or exceeds 90 MME/day, an "opioid care coordination alert" will be triggered and the pharmacist must contact the prescriber. "Having to calculate the MME per day is going to be a real pain in my butt—it's time not well spent from my standpoint," Fox complained.

"Drug management programs" that limit access to opioids may be considered for patients at risk for prescription opioid abuse. CMS has been at pains to explain that 90 MME/day is not an absolute limit and that the new regulations do not represent a one-size-fits-all approach.

Vega maintains that only "a small proportion of Medicare patients with either chronic disability or multiple chronic illnesses and chronic-type pain are at risk for abuse or overdose." He suggests that "because the CMS is a major payer and there is this national crisis, this is an overreaction."

Almost one third of Medicare Part D recipients were prescribed opioids in 2017, at a cost to CMS of $3.4 billion. However, both prescription rate and costs were lower than in 2016.


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