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ICYMI--Pittsburgh Post-Gazette: “Restrictions on opioid prescriptions fall short, senators say”

January 26, 2018

Washington, D.C. -U.S. Senators Pat Toomey (R-Pa.), Sherrod Brown (D-Oh.), Rob Portman (R-Oh.), and Tim Kaine (D-Va.), authors of the Stopping Medication Abuse and Protecting Seniors Act, which was enacted into law to help ensure Medicare beneficiaries at risk of painkiller abuse receive appropriate care, believe that the program is not being implemented as Congress intended. The senators addressed their concerns in a letter to the administrator of the Centers for Medicare and Medicaid Services, noting that the CMS proposal would leave too many beneficiaries at risk of overdose.

Read more in today's Pittsburgh Post-Gazette:

Restrictions on opioid prescriptions fall short, senators say
By Tracie Mauriello
The Pittsburgh Post-Gazette
January 25, 2017

WASHINGTON - Regulators are tightening controls on access to opioids by patients who fill prescriptions from multiple doctors at multiple pharmacies, but the effort is falling short of what lawmakers intended.

Passed in 2016, the Comprehensive Addiction and Recovery Act allows insurers to require Medicare beneficiaries who are at risk of addiction to get all their opioids through one provider and one pharmacy.

But regulators are defining "at risk" too loosely, according to the senators who crafted the provision. A patient would be able to fill opioid prescriptions from three different doctors at three different pharmacies without triggering the "lock-in" limitation.

"This is not having the outcome we wanted it to," said U.S. Sen. Sherrod Brown, D-Ohio, who wrote the "lock-in" provision with U.S. Sen. Pat Toomey, R-Pa. "It's not as effective as we thought."

Mr. Brown, Mr. Toomey, and U.S. Sen. Tim Kaine, D-Va., joined the CARA bill's prime sponsor, Rob Portman, R-Ohio, in asking the Centers for Medicare and Medicaid Services for changes.

"The current proposal would not achieve the full potential of this tool to both limit opioid diversion and help ensure that at-risk beneficiaries are receiving appropriate care. We believe that more can be done," the senators wrote in a letter to CMS.

The Government Accountability Office also has called the proposed criteria inefficient.

They allow insurers to lock in Medicare beneficiaries who are prescribed the equivalent of 90 milligrams or more of morphine daily if they have more than three prescribers and use more than three pharmacies. The lock-in authorization also would be triggered for patients who meet the 90-milligram threshold and have more than five prescribers, regardless of the number of pharmacies that filled them. Hospice and patients and cancer patients would be exempt, and patients could appeal restrictions.

Medicare's dosing threshold is looser than the 50 milligram morphine equivalency the Centers for Disease Control and Prevention uses to identify patients at risk of addiction. Ninety milligrams of morphine is equivalent to, for example, 9 pills of hydrocodone-acetaminophen 10/325 daily.

About 33,000 of Medicare's 48 million beneficiaries would meet CMS's proposed definition of at-risk, but the Government Accountability Office estimates that 727,000 Medicare recipients are at risk of harm from opioids. That's the number being prescribed more than the equivalent of 90 milligrams of morphine daily, regardless of the number of prescribers or pharmacies.

Senators such as Mr. Toomey and Mr. Brown say that's a more reasonable threshold.

They also want CMS's definition of "at risk" to include concurrently prescribed opioids and benzodiazepines, which enhance euphoric effects and increase chances of overdose.

The Pew Charitable Trusts also weighed in on the rule making. It is asking regulators to use the lower CDC threshold, to allow insurers to establish their own additional criteria to identify at-risk beneficiaries and to expand the list of controlled substances subject to the lock-in provision.

Senators want Medicare to use more stringent criteria that are more closely aligned with rules that already apply to Medicaid and commercial insurance. Those rules have been successful, Toomey spokesman Steve Kelly said.

"The idea that the federal government has not employed these safeguards in Medicare - the largest federally funded health care program - shows a lack of adaptation to dealing with this crisis," Mr. Kelly said. "With thousands of Pennsylvanians dying and suffering from the heroin and painkiller epidemic, Sen. Toomey believes a more aggressive approach is warranted."

Limiting patients to a single prescriber and pharmacy for opioids keeps drug seekers from doctor shopping, and protects others from unintentional over-medicating by physicians may not be aware of prescriptions written by other providers, Mr. Brown said.

"We need to address both," he said. "We have to get [regulators] to re-examine this."


In 2016, Congress passed the Comprehensive Addiction and Recovery Act (CARA). Among its provisions, CARA included Senator Toomey's bipartisan Stopping Medication Abuse and Protecting Seniors Act. This legislation intends to prevent "doctor shopping"--a practice by which a Medicare beneficiary visits multiple physicians who unknowingly write redundant opioid prescriptions. Furthermore, it provides Part D plan sponsors the ability to restrict individuals who are at risk of abusing and/or diverting prescription drugs to a single doctor and pharmacist for their prescriptions, an effective tool already used in Medicaid and commercial insurance.

Read the full letter to CMS.