In the most alarming story of the week, the New York Times reports that a new Medicare regulation threatens to halt reimbursement of opioid medications for 1.6 million chronic pain patients. Other top developments include a new CDC analysis of fatal drug overdoses for the years 1999-2016; a study concluding that opioids are no better than nonopioids for acute dental pain; an economist’s report finding that nearly a million people were knocked out of the workforce in 2015 due to opioids; and the arrest of a drug kingpin for allegedly trafficking enough fentanyl to kill 10 million people.Insurance
In debates about how to contain the opioid epidemic, the most emotional, polarized issue is whether efforts to curb overprescribing of opioids, led by public health authorities and advocates, may eventually harm—or already are harming—pain patients. The latter fear being cut off their meds, which, some of them say, could force them either to buy illicit opioids in the streets or even to escape unmanaged pain via suicide.
The new Medicare rule appears to present a concrete instance in which the pain patients’ fears are justified. The rule, scheduled to take effect January 1, would block reimbursement for very strong opioid prescriptions (doses greater than 90 MME [morphine milligram equivalent] per day) lasting more than seven days except for cancer or hospice patients, according to the Times.
In its defense, the Centers for Medicare and Medicaid Services did face a situation that certainly looks like severe overprescribing on its face, with “a staggering one in three of 43.6 beneficiaries” being prescribed opioids. Although CMS claims the rule—which becomes final in April, its notice-and-comment period having elapsed in March—is based on the CDC’s 2016 guidelines for opioid prescribing, several supporters of the CDC guidelines tell the Times that that’s hogwash. (The CDC guidelines urge doctors not to increase a dose above 90 MME per day; they don’t recommend abruptly denying patients opioids they’ve been using for years.) “Even if we walk away from using opioids for back and knee pain,” Dr. Erin Krebs tells the paper, “we can’t walk away from patients who have been treated with opioids for years or even decades now. We have created a double tragedy for these people.” (Krebs, of the University of Minnesota, authored a study published in JAMA last month finding that opioids were no better for treating chronic knee and back pain than nonopioids.)
In a bit of unfortunate timing, concurrent with the NYT story, Cigna proudly revealed that it has succeeded in bringing down its insureds’ opioid use by 25%, as The Hill and Forbes each report. (According to Forbes, the company claims that it hasn’t achieved that goal by denying claims, but, rather, by “reaching out to doctors” to make sure they understand how their prescribing practices compare to CDC guidelines and the practices of other doctors.)
The new CDC report analyzes years that have been previously studied (1999-2016), so it treads some familiar ground. Nevertheless, there are noteworthy, disturbing findings:
The Journal of American Dental Association carries a study—a review of reviews, really—in its April issue finding that opioid medications are no better than nonopioids for alleviating acute dental pain, and have higher rates of adverse events. (The result tends to reinforce the finding of the Krebs study, mentioned above.)
The study coincides with the announcement, reported by the AP among others, by the American Dental Association that it is urging members to “eliminate opioids from your arsenal if at all possible,” and that it supports statutory 7-day limits on prescriptions for acute pain. Interestingly, dentists are “the leading prescribers of opioids for teens,” according to the AP. According to Chicago Tonight, dentists were also the “top specialty prescriber” of opioids in 1998, accounting for for 15.5 percent of all US opioid prescriptions, though the percentage had dropped to 6.4% by 2012.
Although everyone knows about the more than 450 lawsuits that state and municipal officials have brought against opioid manufacturers and distributors across the country, not everyone appreciates the tension that exists within the two main plaintiffs’ camps. The municipalities are profoundly mistrustful of the states (represented by state attorneys general), fearing that if the state AGs control a global settlement, settlement moneys will flow into general state coffers and will never trickle down to local jurisdictions to reimburse the opioid-related expenses—for, say, first responders, morgues, foster care, or neo-natal abstinence syndrome—that prompted the lawsuits in the first place. This is what happened, many have complained, when state AGs settled coordinated tobacco litigation in the late 1990s.
That tension flared into public view this past week, STAT reported, when Tennessee attorney general AG Herbert H. Slattery, III, actually intervened in three suits filed by municipalities in his state in an effort to seize effective control of those cases. The local district attorneys bringing the suits publicly fired back in the Kansas City Star, belittling a cheap settlement 26 state AGs obtained from opioid manufacturers in 2007 (just $19.5 million total) and warning: “”The results of this failed effort have been another decade lost to growing opioid fueled abuse, addiction, and death.” The deep tensions within the plaintiffs’ camp are, in my view, an important obstacle to a quick global settlement of the litigation.
Mexican drug kingpin Francisco Quiroz-Zamora, a member of the Sinaloa cartel, was arraigned in Manhattan this week on charges of importing 44 pounds of fentanyl, according to the Washington Post. Given that 2.5 mg of fentanyl can constitute a fatal dose, the Post calculates that the drugs could kill 10 million people. Though Quiroz-Zamora was seized by a DEA-led, joint federal-state task force, he is being prosecuted by New York City’s Special Narcotics Prosecutor. (Notwithstanding Trump Administration saber-rattling earlier this month, there has been no discussion so far of anyone trying to bring a federal death penalty prosecution against Quiroz-Zamora.) The special prosecutor’s press release says the office’s fentanyl seizures were up 1220% from 2016 to 2017, from 35 pounds to 491 pounds.
In other disturbing fentanyl news: