Living with Chronic Pain

2019 Proposed Medicare Changes Affect Prescription Pain Medications


Coverage for high doses of opioids will change for all Medicare beneficiaries under the Medicare Plan D proposed 2019 regulations. The U.S. government is concerned about the opioid epidemic and is committed to being proactive to combat the overuse and abuse of these medications. However, many individuals with chronic pain conditions have responsibly used opioid therapy for many years to treat their pain and are concerned that their treatment regimen will be affected by these proposed regulations.

Proposed regulations on prescribed opioid dosages

Under the proposed Medicare Part D new regulations, the maximum opioid dosage would be 90 MME (Morphine Milligram Equivalent) per day. Therefore, the covered “ceiling” dosage of hydrocodone would be 90 mg per day, and the “ceiling” dosage for oxycodone would be 60 mg per day. The new proposed regulations also include a “hard edit” rule which would require pharmacists to talk with the prescribing doctor and insurance company in the event that a higher dosage of an opioid is required. The Medicare-approved insurance company would make the final decision on this request. While the “hard edit” regulation is being considered for approval, CMS (Center for Medicare and Medicaid Services) could approve a temporary seven-day supply of opioids with a new prescription from a physician. However, this seven-day supply would be a one-time approval.

Proposed regulations on medication combinations

Medications, such as gabapentin and pregabalin, are often prescribed in combination with opioids in an effort to increase their effectiveness. These drug combinations would also be monitored under the proposed regulations as the combination of these medications increases the risk of overdose. The drug combination of opioids and benzodiazepines would also be closely monitored for the same reason.

Chronic pain community concerns

The current administration's proposal to make it more difficult for Medicare patients to be prescribed high doses of opioid pain medication is considered by some to be a risky regulation. Many individuals have been on high doses of opioids for many years to manage their chronic pain conditions. Studies show that the sudden reduction in opioid dosage often causes severe withdrawal symptoms, increased pain levels, and decreased quality of life. As many as 1.6 million Medicare beneficiaries have either met or exceeded a prescribed opioid dose of 90 mg MME at least once in 2016. If these proposed regulations are put in place, it will hasten a continuing pattern of involuntary opioid tapering and discontinuation.

The chronic pain community fears that these proposed changes will increase illegal drug use and suicides. The legitimate fear about decreased quality of patient care resulting from these proposed regulations is also present in the hospice and end-of-life care communities, long-term care facilities, and cancer centers; however, most of these will be excluded from the new regulations.

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