As I’ve said many times, to solve the complex problems of opioid misuse and overdose, policymakers across the country are blindly and blithely reaching for the simplest solutions. Typically, these solutions focus on reducing opioid prescribing to--or beyond--the bare minimum. Because these policies often are enacted with very little forethought and very little concern for the unintended consequences, policymakers sometimes unhappily discover after the fact that they may not have solved the original problem, but instead, have created a new one that may be even worse. This “ready, fire, aim” approach to policymaking, is, I fear, what we are facing now in Oregon, and we’re not going to sit idly by while it happens.
Currently, Oregon’s Health Evidence Review Commission (HERC), through its Value-based Benefits Subcommittee (VbBS), is considering a policy proposal from the state’s Chronic Pain Task Force that would deny coverage of opioids for most chronic pain conditions beyond 90 days, mandate the taper and discontinuation of opioid therapy for patients currently receiving it, and instead cover only a variety of non-opioid treatments for people living with long-term pain. While AIPM strongly supports increased use of nonpharmacological treatments and educates practitioners on the benefits of an integrative approach to treating pain, we are gravely concerned with the access to care issues that would be implicated if this policy were to be adopted as it is written.
This policy proposal will apply to all Oregon Medicaid patients diagnosed with conditions of the back and spine, and with chronic pain, except those who qualify for palliative care. Under the current proposal, between six weeks and 90 days, the use of opioids will only be allowed if several conditions are met, including that they must be prescribed in conjunction with therapies such as spinal manipulation, physical therapy, yoga, or acupuncture. What’s more, no opioids whatsoever will be covered after 90 days except for purposes of tapering a patient down to 0 MME/day within one year, regardless of how a patient’s pain and function respond to the taper.
Given that AIPM’s top priority is advancing access to integrative pain care, it would be easy to assume that we would support this policy change—we do not.
Health care providers treating patients living with complex pain conditions need access to all the tools in the toolbox, including both opioid and non-opioid medications, and non-pharmacological treatments. While we focus on removing barriers to non-pharmacological treatments that have not, to date, been adequately covered, we also have to be vigilant to prevent the erection of new barriers that block our access to tools that have been fully available. While some ratcheting back of opioid prescribing for chronic pain is not only appropriate but necessary, it should not be an all-or-none proposition. Despite the scarcity of randomized controlled trials of the long-term efficacy of opioids (which, by the way, is the same scarcity of RCTs we face with non-opioid treatments for pain), we know from clinical experience that there are some people with chronic pain who do well on long-term opioid therapy, and whose quality of life is likely to be markedly diminished if this policy goes into effect.
We have three major concerns with this proposed policy:
- Despite hinging access to opioid treatment on use of one of more non-opioid therapies, the Oregon proposal makes no plan for ensuring that the covered non-opioid therapies are geographically accessible to patients, or that there is a sufficient supply of providers for these therapies. See AIPM’s letter related to access to care concerns.
- The proposed changes do not mention what action should be taken if the patient begins to experience clinically significant increases in pain and decreases in function upon tapering the opioid dose. Appropriate medical care requires that a taper to be paused, stopped, and possibly reversed, based on documentation of detrimental changes to the patient’s functioning resulting from the taper. See AIPM’s letter related to forced opioid tapering.
- The Oregon proposal is unsupported by current treatment guidelines related to opioid prescribing, including those issued by the Centers for Disease Control and Prevention (CDC) in 2016, Canada in 2017, the U.S. Veteran’s Administration, and professional medical associations. See the sign-on letter that I joined on behalf of AIPM.
While it was recommended that all comments for the August 9th meeting of HERC/VbBS be in by July 30 to ensure sufficient time for them to be considered, comments will still be accepted up until August 7th. Comments must be no longer than 1000 words and can be submitted to firstname.lastname@example.org.
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Dr. Twillman testified at the in-person meeting of HERC/VbBS on August 9, 2018. See his testimony related to forced opioid tapering and the need for any taper plan to contain a provision allowing that taper to be paused, stopped, and/or reversed if lower doses are associated with poorer function.