Opioid abuse: Understand guidelines to protect patients and your practice

Opioid abuse has become an ever increasing epidemic in the United States. The use of opioids is on the rise across the entire country, but individuals with Medicare Part D are among some of the most affected. As of 2016, one in three Medicare Part D beneficiaries had received at least one prescription for opioids and one in 10 received prescriptions for regularly scheduled opioids.

Due to this increased health safety concern, public health programs such as CMS and the CDC have launched an extensive investigation to find a solution to this epidemic. CMS has started numerous initiatives to investigate patients and prescribers affected by this epidemic.

Through these investigations, they hope to identify problems and create new guidelines for prescribers to follow in an effort to reduce opioid abuse especially in patients on Medicare Part D. The CDC has come out with new opioid prescribing guidelines those regarding alternative options to treat chronic pain. All of these changes come with increased scrutiny on prescribers with potentially dire consequences including loss of medical licensure for failure to adhere to the guidelines. This makes it crucial to remain up to date on all of the new opioid prescription guidelines.
 

Identify at-risk patients

The first step a prescriber can take to lower opioid abuse is to work to identify at-risk patients. CMS has found that there are two groups of patients at high risk for opioid use disorder. The first patient population is patients that are on high amounts of opioids, defined as an average daily morphine equivalent dose (MED) greater than 240 mg for 12 months. While these patients may have chronic pain conditions requiring high-dose pain medication for control, the high doses put them at increased risk for development of an addiction. The CDC does not recommend opioids be used as first-line treatment for chronic pain disorders. Instead, it recommends non-pharmacological treatments such as osteopathic manipulative treatment or physical therapy or non-opioid pain medications. The other patient population are patients who have received large amounts of opioids, had four or more prescribers, and filled prescriptions at four or more pharmacies-a practice known as doctor shopping. Using traditional methods of identification has allowed these patients to avoid prescribers from noticing patterns of opioid use and abuse.

Understand the new CDC guidelines

In 2017, the CDC came out with new guidelines focused on improved patient-physician communication regarding treatment goals and outcomes. The new guidelines state that opioids should only be considered if the risks outweigh the benefits, which is best determined by discussing your patient’s goals of pain relief. If opioids are prescribed, the patient should be started on the lowest dose of immediate release medication and increased as needed from there. The CDC’s new recommendation is to avoid a dose greater than 90 morphine milligram equivalents per day. Along with establishing goals before treatment, the CDC recommends frequent follow up to monitor effectiveness and compliance.
 

Understand the CMS Opioid Misuse Strategy

CMS is the national leader in research and guidelines for Medicare and Medicaid. It has taken great interest in this epidemic and has worked to create programs and guidelines to help prescribers reduce opioid over-prescription. The organization has identified four priority areas: Within each of these priority areas, CMS has worked to create programs to achieve its goals of decreasing opioid overprescribing.

The four areas are:
Implement person-centered and population-based strategies to reduce the risks of opioids. CMS has worked with quality improvement organizations and action networks to improve the access doctors have to evidence-based guidelines.
Being up to date on current practices is important to provide quality care for patients while avoiding penalties for over prescribing. By January 2019, CMS will require all prescribers under Medicare Part D to register as prescribers. This will allow agencies such as the NBI MEDIC Pill Mill Doctor Project to better monitor prescribing trends, allowing them to identify prescribers who need education or law enforcement involvement. CMS guidelines for monitoring include the following:

• Prescriptions exceeding 90 morphine milligram equivalents per day
• Prescriptions for greater than seven days
• Prescriptions for extended release or long acting opioids
• Prescriptions for opioid treatment without other therapies

Expand naloxone use when clinically appropriate. Naloxone is a medication that can be used to reverse respiratory depression caused by an opioid overdose. CMS believes that increased accessibility to this medication will decrease the amount of deaths due to opioid overdose. They are requiring that naloxone be on Medicare Part D formularies and the preferred drug list. Along with increasing the availability of naloxone, CMS suggests that doctors begin to prescribe it along with opioids.

Expand tools required to diagnose and treat opioid use disorder. Medication-assisted treatment (MAT), a combination of behavioral and medical treatment, has been proven to be the most effective treatment for opioid use disorder. Eighteen months after treatment with MAT, patients were two times more likely to avoid opioids when compared with patients not treated with MAT. CMS is working to improve access to MAT by increasing the locations across the country along with education for prescribers about this effective treatment.

Increase use of evidence-based practices for pain management. Just like guidelines for prescribing opioids, CMS is working to increase the distribution of alternative treatments for pain. They are working to implement EHR protocols, trainings, webinars, and education to help prescribers understand all of the treatment options. CMS is also working to increase coverage of these alternative treatments so they will be more accessible to patients.

The CDC has also recently developed an “Opioid Prescribing Guideline” mobile app that serves as a quick reference guide for healthcare professionals to help apply the recommendations of the CDC Guideline for Prescribing Opioids for Chronic Pain in clinical practice. The tool is intended to educate providers about the prescription opioid overdose epidemic and to inform clinical decision-making. The app was released in 2016, and most recently updated in January 2017.

There is tremendous scrutiny over prescription of opioid medications for the use of pain management, especially for Medicare Part D participants. Make sure to keep up with the current CDC and CMS guidelines on prescribing opioids along with their recommendations on alternative treatments for chronic pain. By being more conscious about prescribing opioids, physicians can protect their patients and themselves from becoming victims of the opioid epidemic.