Medicare officials thought they had finally figured out how to do their part to fix the troubling problem of opioids being overprescribed to the old and disabled: In 2016, a staggering 1 in 3 of 43.6 million beneficiaries of the federal health insurance program had been prescribed the painkillers.
Medicare, they decided, would now refuse to pay for long-term, high-dose prescriptions. Some medical experts have praised the regulation as a check on addiction.
But the proposal has also drawn a broad and clamorous blowback from many people who would be directly affected by it, including patients with chronic pain, primary care doctors and experts in pain management and addiction medicine.
Critics say the rule would inject the government into the doctor-patient relationship and could throw patients who lost access to the drugs into withdrawal or even provoke them to buy dangerous street drugs.
“The decision to taper opioids should be based on whether the benefits for pain and function outweigh the harm for that patient,” said Dr. Joanna L. Starrels, an opioid researcher and associate professor at Albert Einstein College of Medicine. “That takes a lot of clinical judgment. It’s individualized and nuanced. We can’t codify it with an arbitrary threshold.”
The rule means Medicare would deny coverage for more than seven days of prescriptions equivalent to 90 milligrams or more of morphine daily, except for patients with cancer or in hospice. The Centers for Medicare and Medicaid Services estimates that about 1.6 million patients currently have prescriptions at or above those levels. The rule would take effect on Jan. 1, 2019.
Dr. Stefan G. Kertesz, who teaches addiction medicine at the University of Alabama at Birmingham, submitted a letter in opposition, signed by 220 professors in academic medicine, experts in addiction treatment and pain management, and patient advocacy groups.
“A lot of the opioid dose escalation between 2006 and 2011 was terribly ill advised,” Kertesz said. “But every week I’m trying to mitigate the trauma that results when patients are taken off opioids by clinicians who feel scared. There are superb doctors who taper as part of a consensual process that involves setting up a true care plan. But this isn’t it.”
If the rule takes effect, Mark Zobrosky’s experience could be a harbinger for many patients. Zobrosky, 63, who lives in the North Carolina Piedmont, takes opioids for back pain, which persists despite five surgeries and innumerable alternative treatments. He has an implanted spinal cord stimulator that sandpapers the edge off agony, and has broken four molars from grinding because of pain, he said. He receives Medicare as a result of his disability, including a private plan that pays for his drugs.
To prepare for mandatory reductions, his doctor has tapered down his daily dose. In February, Zobrosky’s pharmacist told him that his insurance would no longer cover oxymorphone. His out-of-pocket cost for a month’s supply jumped to $1,000 from $225, medical records show.
“I can’t afford this for very long and I’m nervous,” he said.