Pain – Addiction Treatment Forum

CMS Pushing 7-Day Limit on Initial Opioid Scripts

February 11, 2018

“The Centers for Medicare & Medicaid Services (CMS) is proposing that beginning in 2019, initial opioid prescriptions for acute pain be limited to 7 days.

The agency is also suggesting in the 2018 Draft Call Letter that Medicare Part D prescription drug plans monitor patients who take medications considered to be “potentiators” of opioid misuse and opioid-related adverse events — specifically, gabapentin and pregabalin.

Noting an alarming increase in gabapentin use to treat pain and concurrent opioid and gabapentin use, CMS is asking for comment on whether it is useful to more closely monitor beneficiaries receiving these prescriptions.

The CMS proposal came as a US House committee took a closer look at Medicare’s oversight of opioid use. At the February 6 hearing, members of the Ways and Means Health Subcommittee said there are few data on opioid use among older Americans and that Medicare has done a poor job of encouraging prevention and treatment.”

Read more at: https://www.medscape.com/viewarticle/892412 (log-in required)

Source: Medscape.com – February 7, 2018

Need for Medicare Reimbursement for OTPs Cited in DC Briefing

December 13, 2017

By Alison Knopf

Senior citizens are not immune from opioid use disorders (OUDs), but Medicare does not cover treatment in an Opioid Treatment Program (OTP). The American Association for the Treatment of Opioid Dependence (AATOD), Advocates for Opioid Recovery (AOR), and the Collaborative for Effective Prescription Opioid Policies (CEPOP), are trying to change this.

AOR and CEPOP sponsored a briefing at the U.S. Capitol Visitor Center in Washington D.C. on November 15. The meeting focused on increasing access to medication-assisted treatment, specifically with methadone and buprenorphine. While opioid briefings have become almost a daily event on Capitol Hill, this one was special in that it brought out the need for better access to OTPs.

The problem:

Seniors commonly take opioids for pain management; in 2016, one out of every three Medicare beneficiaries received at least one prescription opioid through Part D, Medicare’s insurance coverage for pharmaceuticals
Prescription opioids have a high risk for misuse or abuse
Symptoms of prescription opioid misuse or abuse may be hard to recognize in older adults, because they resemble some symptoms that may accompany aging, such as memory changes
Methadone is covered by Part D only when prescribed for pain, not for treating OUD, because in Part D it cannot be dispensed by prescription at a retail pharmacy
Methadone cannot be covered by Medicare Part D because it is administered through outpatient OTPs

The solution:

Congress should immediately authorize Medicare coverage of all medications approved for treating OUDs–methadone, buprenorphine, and extended-release naltrexone. Currently, only in OTPs can methadone be dispensed to treat OUDs.

DC Briefing

At the November 15 briefing, Angela Caldwell, MS, lead counselor and program coordinator at Montgomery Recovery Services, an OTP in Rockville, Maryland, described a case of an older patient whose insurance coverage was terminated when she became eligible for Medicare at the age of 65.

The solution wasn’t perfect. The program found a physician willing to continue treating her with methadone, but as a pain patient. However, the ways methadone is prescribed for chronic pain and for addiction are very different. For pain, dosing is by pill and split throughout a 24-hour period. For addiction, patients need to take only one liquid dose every 24 hours.

The patient under discussion had been maintained on 70 milligrams; the physician lowered her dose to 40 milligrams. “It wasn’t ideal, but it was the best we had to work with,” said Ms. Caldwell. “We need to treat this as a disorder.”

Ms. Caldwell went on to read a letter from a 66-year-old patient in the program, who has stayed off heroin for 23 years, thanks to the OTP. He attends group sessions at Montgomery Recovery Services, where he can share his fears. (He has severe depression and anxiety attacks.)

“My depression is multiplied tenfold since, when I turned 65, I was told I might not be able to continue my treatment,” he wrote. “I don’t want to guess what might happen to me.”

With Coverage, Services Increase

Mark Parrino, MPA, AATOD president, has been working with Congressional committees on Medicare Part B coverage. He said at the November 15 briefing that the increased access to treatment resulting from the expansion of Medicaid, and from the decision by states to allow Medicaid to cover treatment in an OTP, have made a huge difference in the opioid epidemic. He explained that when states add Medicaid reimbursement, the use of OTP services increases by 20%.

In states where Medicaid does not pay for OTPs, 85% of the patients make out-of-pocket payments, said Mr. Parrino. “If they can’t do that, they can’t get into treatment.” He added that in states that have robust Medicaid-OTP programs, like New York, California, and Pennsylvania, 85% to 90% of patients in OTPs are covered by Medicaid.

“This is not a criticism of treatment centers that do not use medications to treat opioid use disorders,” said Mr. Parrino. “But there are only 1,500 OTPs in this country. That is not a profound number, and it’s woefully inadequate to meet the increasing demand for services.”

Because of the addiction epidemic, some of the bias against OTPs is evaporating, said Mr. Parrino. “People are starting to say, ‘We need treatment in our community.’”

Medical Experts and Former Legislators Call for Coverage

Mary Bono, former representative from California, and founder of CEPOP, stressed that treatment with buprenorphine or methadone reduces the risk of death. “I’ve had employees who are in methadone treatment,” she said. “Congress has to get this done,” she said of Medicare coverage of methadone.

Patrick J. Kennedy, former representative from Rhode Island, and an outspoken proponent of treatment, called for funding. “We have great recommendations, but where is the money to implement them?” he asked. “Either this is a national emergency, or it isn’t.”

Frances Levin, MD, past president of the American Academy of Addiction Psychiatry, noted that the presence of fentanyl in almost all drugs sold on the street as opioids has drastically changed the situation for people who need treatment. “We are testing all patients, and most are coming up positive for fentanyl,” said Dr. Levin, who is also Kennedy-Leavy Professor of Clinical Psychiatry at Columbia University, and Chief of the Division on Substance Abuse at New York Presbyterian Hospital. “They didn’t even know they had taken it,” Dr. Levin said, referring to fentanyl.

She added that even patients who are tolerant to opioids can still overdose on fentanyl. “It’s 50 times stronger than morphine,” she said. “Clinicians are finding that even two naloxone kits aren’t necessarily enough” to reverse a fentanyl overdose.

The funding needed to reverse the opioid epidemic—$15 billion a year, according to Mr. Kennedy—isn’t likely to materialize any time soon, said Ms. Bono. “There isn’t going to be enough funding, so we have to spend our money wisely. Medicare coverage for methadone is a no-brainer.”

Mr. Parrino recommends that Medicare Part B cover federally approved medications utilized in an OTP in addition to all the comprehensive services, which are offered through OTPs.

The briefing, which was streamed on Facebook, was moderated by Brianna Ehley of Politico.

A fact sheet from the briefing is available at: http://www.atforum.com/pdf/AOR-HILL-BRIEF-FACT-SHEET-FINAL.pdf

Chronic Pain + Mental Health Disorder = Risk of Opioid Overdose

December 11, 2017

“A new study finds that over 60 percent of individuals who died from an opioid overdose had been diagnosed with a chronic pain condition, and many had been diagnosed with a psychiatric disorder.

Researchers at Columbia University Medical Center reviewed more than 13,000 overdose deaths with the study the first to determine the proportion of those who died of an opioid overdose with chronic pain.

The analysis is timely as according to the US Centers for Disease Control, the number of opioid-related deaths has quadrupled, from 8,048 in 1999 to 33,091 in 2015.

The findings underscore the importance of providing substance use treatment services in conjunction with behavioral interventions for people with chronic pain.”

The study, “Service Use Preceding Opioid-Related Fatality,” appears online in the American Journal of Psychiatry.

Source: PsychCentral.com – November 29, 2017

SAMHSA Reaffirms Efforts to Address the Public Health Emergency on the Opioid Crisis

October 31, 2017

Today President Donald Trump announced new action to help 11 million Americans affected by the opioid crisis.

President Trump’s declaration of the opioid crisis as a public health emergency reaffirms the role of the Department of Health and Human Services (HHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) as leaders in solving one of America’s most pressing public health issues. The President recently appointed Dr. Elinore F. McCance-Katz as the first Assistant Secretary for Mental Health and Substance Use, underscoring the urgency of the issue. “SAMHSA looks forward to continuing its role in helping American communities fight the opioid crisis through evidence-based programs in prevention, treatment, and recovery services,” said Dr. McCance-Katz. “The announcement today by President Trump reflects our commitment to this cause and inspires us to redouble our efforts on behalf of all who have suffered the effects of opioid addiction.”

HHS is implementing five specific strategies that are guiding SAMHSA’s response. The comprehensive, evidenced-based Opioid Strategy aims to:

Improve access to treatment and recovery services to prevent the health, social, and economic consequences associated with opioid addiction and to enable individuals to achieve long-term recovery;
Target the availability and distribution of these drugs, and ensure the broad provision of overdose-reversing drugs to save lives;
Strengthen public health data reporting and collection to improve the timeliness and specificity of data and to inform a real-time public health response as the epidemic evolves;
Support cutting-edge research that advances our understanding of pain and addiction, leads to the development of new treatments, and identifies effective public health interventions to reduce opioid-related health harms; and
Advance the practice of pain management to enable access to high-quality, evidence-based pain care that reduces the burden of pain for individuals, families, and society while also reducing the inappropriate use of opioids and opioid-related harms.

Source: SAMHSA.gov – October 26, 2017

The Social Life of Opioids: New Studies Strengthen Ties Between Loss, Pain and Drug Use

September 28, 2017

In the story of America’s opioid crisis, a recent tripling in prescriptions of painkillers is generally portrayed as the villain. Researchers and policy makers have paid far less attention to how social losses—including stagnating wages and fraying ties among people—can increase physical and emotional pain to help drive the current drug epidemic.

But a growing body of work suggests this area needs to be explored more deeply if communities want to address the opioid problem. One study published earlier this year found that for every 1 percent increase in unemployment in the U.S., opioid overdose death rates rose by nearly 4 percent.

Source: Scientific American

Women Bear Greater Burden of Opioid Epidemic

July 5, 2017

“The face of the U.S. opioid epidemic is becoming increasingly white and increasingly female, just as it was some 135 years ago.

The impact of the epidemic has been severe for both males and females, but statistics show greater harm occurring among women and girls. Chief among these are overdose deaths from prescription pain killers. Between 1990 and 2010, these deaths increased among men by 265 percent, while the number grew by 400 percent among women, according to the Centers for Disease Control and Prevention (CDC).

Yet when the CDC issued its guideline on opioid-prescribing for chronic pain last year, the recommendations didn’t distinguish between males and females.

“The prescribing guidelines are gender-blind,” said Mishka Terplan, MD. “That’s unfortunate.”

Source: AMA-ASSN.org – June 27, 2017

From Opioid-Free to Long-Term User, In One Operation: Study Shows Key Role of Surgery

April 18, 2017

“Having surgery always comes with risks. But a new study suggests a new one to add to the usual list: the risk of becoming a long-term opioid user.

About 6 percent of people who hadn’t been taking opioids before their operation, but were prescribed the drugs to ease their post-surgery pain, were still getting the drugs three to six months later, the study finds.

That’s long after the window considered normal for surgical recovery, say the authors of the national study, published in JAMA Surgery. The rate didn’t differ between patients who had minor surgery and those who had major surgery, but it was slightly higher in southern states.”

Source: MedicalXpress.com – April 12, 2017

Why Women Use—and Misuse—Opioids

April 13, 2017

By Barbara Goodheart, ELS

How different are women from men, when it comes to using—and misusing—opioids?

More different than you might think, it turns out, according to CDC Vital Signs, a publication of the Centers for Disease Control and Prevention. Women are more likely than men to have chronic pain, and to use prescription opioids for longer periods, in higher doses. They also tend to become physically dependent on opioids more easily than men, even after using smaller amounts for shorter periods.

The outcomes of opioid use and misuse reflect women’s greater susceptibility. Between 1999 and 2010, overdose deaths from prescription pain killers increased 237% among men, but the rise was far higher among women—more than 400%.

The situation with heroin usage is similar. CDC Vital Signs indicates that between 2002 and 2013, heroin use rose 50% among men, but it increased 100% among women. These examples are from a new 35-page report, White Paper: Opioid Use, Misuse, and Overdose in Women, published in December by the Office on Women’s Health (OWH), U.S. Department of Health and Human Services (HHS).

This article summarizes the White Paper and highlights important data about women and opioid use and misuse.

Overview: The HHS White Paper

Contents. The White Paper opens with a description of the opioid epidemic and the three areas of the HHS Opioid Initiative (see table), then moves on to prevention and treatment of opioid use disorders (OUDs).

HHS Opioid Initiative

Focus on opioid prescribing practices to reduce OUDs and overdoses
Expand use of naloxone
Expand use of medication-assisted treatment (MAT), to reduce OUDs and overdoses

In addition to citing data, the White Paper highlights factors involved in a woman’s path to opioid misuse, among them life experiences, biological and social influences, geography, and demographic characteristics.

Purpose. The White Paper was commissioned to educate enrolled participants in advance of a September 2016 HHS-OWH national meeting. The goal of the meeting was to prepare participants to understand the impact of the opioid epidemic on women, across age, race, geography, and income, and to issue a post-meeting report on possible solutions to some of the problems discussed in the White Paper.

Underlying Psychological Differences in Women Lead to Riskier Behavior

Why do women behave differently from men when it comes to opioids? Psychological differences, such as women’s more intense opioid cravings, account for some of the riskier behavior. While both sexes are susceptible to psychological and emotional distress, a key difference exists: these distresses are actual risk factors for hazardous prescription opioid use in women, and only in women, studies show; men react to these distresses in other ways.

SAMHSA data (2015) reveal that 4% of females ages 12 and older misused prescription pain relievers during the previous year. Because misuse often leads to involvement of the health care system, it’s not surprising that, CDC data show, every three minutes another woman visits an emergency department because of prescription painkiller misuse.

Women with a substance use disorder are at increased risk of injection drug use, which can lead to viral hepatitis or to HIV. From 2010 to 2014, new cases of hepatitis C among women rose more than 260%—with substance use in part responsible. Younger women risk transmitting the infection to their infants—yet many, serving as caregivers and lacking childcare options, find it difficult to arrange for treatment for their disorder.

Preventing OUDs and Overdoses in Women

Few data exist on preventive measures for women, and studies tend to involve substances other than opioids. The tendency of women to quickly become physically dependent on opioids, mentioned earlier, involves several physiological differences that exist between men and women: metabolic rate, hormone levels, and percentages of body fat. With the risk of opioid-related harm higher in women, investigators see screening and early intervention as key steps in helping to protect women from OUDs and overdoses.

The HHS Opioid Initiative

Opioid Prescribing Practices

Between 2008 and 2012, more than one-third of Medicaid-enrolled women aged 18-44 and more than one-fourth of privately insured women in the same age group were prescribed opioids.

Expanding Naloxone Use in Women

Naloxone offers potentially life-saving treatment, but is under-used in women. A 2016 study found that men were almost three times more likely than women to be given naloxone in resuscitation efforts. With a nasal spray and an auto-injector formulation now available, perhaps more women who need naloxone will be able to obtain it.

The White Paper notes: “Given the trends in increased heroin use among women, increased availability and usage of naloxone may soon be that much more critical to prevent death from overdose among women.”

MAT for Women

Despite “overwhelmingly positive” evidence that MAT is effective, and a recommendation from the CDC that patients with an OUD be offered MAT, each year only 20% of adults—men and women—with an OUD receive MAT. The barriers: cost, access, and stigma.

Many women with an OUD lack the financial and child-care resources available to other women. Even those who can find affordable treatment and decide to enter a program may have problems arranging for child care.

Seeking Solutions

In response to the increasing impact of the opioid crisis on women, the HHS OWH held a national meeting on September 29-30, 2016. The meeting convened a national conversation on how best to address some of the problems described in the White Paper. AT Forum will check with HHS OWH later regarding its findings and recommendations, and, if appropriate, will publish a follow-up article.

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References

AAFP Supports Turn the Tide Rx Campaign to End Opioid Abuse. August 9, 2016. American Academy of Family Physicians Web site. http://www.aafp.org/news/health-of-the-public/20160809turntide.html. Accessed April 12, 2017.

Anson P. Post-Surgical Pain Guidelines Reduce Use of Opioids. Pain News Network Web site. February 18, 2016. https://www.painnewsnetwork.org/stories/2016/2/18/guidelines-for-post-surgical-pain-discourage-use-of-opioids. Accessed April 12, 2017.

CDC Vital Signs citing National Survey on Drug Use and Health 2002-2013. http://www.cdc.gov/vitalsigns/heroin/index.html#modalIdString_CDCImage_0. Accessed April 12, 2017.

Center for Substance Abuse Treatment. Chapter 13 – Medication-Assisted Treatment for Opioid Addiction During Pregnancy. In: Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.) http://www.ncbi.nlm.nih.gov/books/NBK64148/# 6.

Chou, R. et al. Management of Postoperative Pain: A Clinical Practice Guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. February 2016, Volume 17, Issue 2, Pages 131-157. http://www.jpain.org/article/S1526-5900%2815%2900995-5/fulltext#back-bib18. Accessed April 12, 2017.

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1.

Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.

Significant Pain Increases the Risk of Opioid Addiction by 41 Percent

July 27, 2016

“What do we really know about the relationship between the experience of pain and risk of developing opioid use disorder? Results from a recent study – the first to directly address this question — show that people with moderate or more severe pain had a 41 percent higher risk of developing prescription opioid use disorders than those without, independent of other demographic and clinical factors.

These results, from researchers at Columbia University Medical Center, were published today in American Journal of Psychiatry.

The researchers analyzed data from a national survey of alcohol and substance use in more than 34,000 adults in two waves, three years apart. At each point, they examined pain (measured on a five-point scale of pain-related interference in daily activities), prescription opioid use disorders, and other variables such as age, gender, anxiety or mood disorders, and family history of drug, alcohol, and behavioral problems.

Participants who reported pain and those with prescription opioid use disorders were also more likely than others to report recent substance use, mood, or anxiety disorders or have a family history of alcohol use disorder.

“These findings indicate that adults who report moderate or more severe pain are at increased risk of becoming addicted to prescription opioids,” said Mark Olfson, MD, MPH, professor of psychiatry at Columbia University Medical Center, and senior author of the report. “In light of the national opioid abuse epidemic, these new results underscore the importance of developing effective, multimodal approaches to managing common painful medical conditions.”

Source: Eurekalert.org – July 22, 2016

Huffington Post Blog: How Nursing Is Helping to Combat the Opioid Epidemic

June 28, 2016

“In April, Deborah Trautman, PhD, RN, FAAN, President and Chief Executive Officer of the American Association of Colleges of Nursing (AACN), the national voice for baccalaureate and graduate nursing education, was asked to provide remarks to the White House Champions of Change for Prevention, Treatment, and Recovery event in Washington, D.C. Recently, I reached out to Dr. Trautman with a few questions in an attempt to garner her thoughts about the opioid epidemic and the role that nursing plays in addressing this nationwide crisis.” She addressed the following questions:

How do you see nursing education changing in the future due to this crisis?
How can consumers partner with their health care provider to address this nationwide problem?
In your opinion, what is the biggest myth about the opioid crisis?

She summarized, “the opioid crisis in the U.S. can only be averted through a collaborative effort of health care providers, consumers and community resources. The CDC offers Guideline Information for Patients to assist consumers with understanding the opioid crisis and to learn how they can partner with their provider to receive effective pain management.”

Source: HuffingtonPost.com – June 23, 2016