Oregon could have some of the country's strictest limits on opioids in chronic pain patients under a proposition that is being considered for the state's Medicaid program. The proposed amendment would limit the coverage of the Oregon Health Plan for five broad chronic pain conditions to 90 days of opioid analgesics and force patients who take opioids longer to be toned down by these drugs within a year.
State officials say taking the step of reducing overdose with opioids has resulted in an overdose epidemic and providing alternative treatments that were previously inaccessible to members of the Oregon Health Plan.
The proposal has angered and frightened many chronic pain patients who believe alternative approaches may not work for everyone and that the decision to discontinue opioids should be made by the doctor rather than the authorities.
"People with chronic pain face really debilitating conditions that affect quality of life, but we still face this major opioid epidemic that causes a lot of abuse and overdose," Dr. Dana Hargunani, Chief Medical Officer of the Oregon Health Authority. "We try to use evidence to guide us, but we very much welcome public participation in the process, and I know that this is a very important issue for many people."
The proposed change came from the Task Force " Chronic Pain ", an ad hoc committee that provides guidelines for reducing opioid use in the Oregon Health Plan. The Oregon Health Plan has a unique structure among the Medicaid government programs, based on a prioritized list of health care services that experts classify according to their importance to patients. State legislators decide where in the prioritized list the line between covered and uncovered services should be drawn.
Currently, the five disputed illnesses – fibromyalgia, chronic pain syndrome, chronic pain due to trauma, other chronic post-procedural pain, and other chronic pain – fall below the limit and thus treatments for these conditions are not covered by the Oregon Health Plan. But according to the Oregon Health Authority, many patients with these five conditions are prescribed opioids. The Oregon Health Plan has no way of knowing if these patients are being prescribed opioids for these chronic pain conditions or for covered services, and therefore can not refuse to cover these prescriptions.
By creating a new entry in the prioritized list above the cutoff line, the Oregon Health Plan would then cover alternative treatments such as yoga, acupuncture, or physiotherapy, but try to limit the use of opioids.
Chronic pain patients rallied in front of OHA offices in Salem last week to protest the change. The organizers of the protest refused to comment on the case because they were afraid of reprisals and feared that they would be denied access to painkillers.
Steve Hix, a 50-year-old Albany man almost completely bedridden with back and back injuries, suffered a day in his wheelchair to protest the opioid restrictions.
"We have a law so that people in this state can have a death in dignity," said Hix. "Why do not we have a law so that we can have a life of dignity?"
In 1990, Hix was hit on his motorcycle by a semi-finished product and suffered a series of crashes in 1994, which made him very extensive spine damage and agonizing pain. His doctor persuaded him to commit suicide and arranged surgery for spinal fusion. He prescribed Hix high doses of opioids to cope with the pain.
For over 13 years, Hix used fentanyl patches and morphine pills to keep his pain at bay, adding medical marijuana as a distraction from his pain. When his doctor announced that he would retire this year, Hix feared he would be cut off from his high doses and slimmed down from high doses to squeeze his unused medication just in case.
"The less medication I took, the more I ended up in bed," said Hix. "The pain I had to endure in order to come to the protest, you could not imagine."
Chronic pain patients are planning to hand their fight over to a subcommittee of the Health Evidence Review Commission, which will examine the proposal at its meeting on August 9. The full commission could give its final approval in October, but the restrictions would most likely come into effect in 2020.
The proposed change reflects a back pain policy that was introduced in 2016 with similar initial and longer-term opioid prescriptions. But this policy has proved difficult.
The prioritized list represents the minimum coverage of the Oregon Health Plan, but care is mainly provided by regional, coordinated care organizations that can not identify the condition in which an opioid prescription is being taken unless they require prior approval.
"It would be extremely difficult to meet criteria for a large category of drugs," Dr. Alison Little, medical director of Medicaid programs at PacificSource Health Plans, who runs the CCO in central Oregon. "They are prescribed very often, so it was a challenge to implement this policy."
PacificSource sent letters to physicians in 2016 to inform them about the new rules for lower back pain, and focused on rejuvenating patients with the highest daily opioid doses to comply with the guidelines of the Centers for Disease Control and Prevention bring to. These guidelines require that physicians not prescribe more than 90 milligrams of morphine equivalent per day or justify their decision.
However, the CDC guidelines did not provide clear guidance on what to do with patients who had doses above this threshold for an extended period of time. Some doctors have interpreted the guideline as meaning that patients should fall below this threshold, even if they are unwilling to do so.
While studies suggest that higher doses of opioids increase the risk of overdose, there is little research to suggest that tapering, especially forced tapering, improves patient outcomes.
Little said she had heard little pushback from the lumbar spine guidelines from patients or doctors and was not sure how many patients had completely rejuvenated from opioids.
"What I do not know is how many patients pay in cash," she said. "We can have limits on how much we pay, but that does not stop them from actually getting more."
According to the Prescription Drug Program, the number of opioid prescriptions in Central Oregon dropped significantly in 2017. However, it is not clear how much of this could be attributed to the changes to the Oregon Health Plan. The number of patients with high opioid doses in the region has also steadily declined since 2015.
Kim Swanson, Director of Behavioral Health at Mosaic Medical and Chairman of the Oregon Pain Standards Task Force, said only a few patients were fully focused on opioids.
"They have been reduced to 50 to 90 milligrams since 2014," she said. "There are still people who take opioids, they have just rejuvenated into a safe dose range."
Across the country, the prescription of opioids has been declining since 2014, while alternative treatments such as acupuncture, chiropractic treatment and physical treatment are being used. Therapy was increased in 2016 and 2017 following the adoption of the new lumbar spine policy.
The proportion of patients with back pain in OHP with an opioid regimen declined slightly from 34.5 percent in 2016 to 33.9 percent in 2017. The proportion of patients with high opioid doses decreased by about 25 percent and at very high doses by 19 percent.
Critics criticize the proposed policy as misguided, as overdose deaths from prescription opioids are decreasing, while deaths from heroin and other drugs are on the rise. Patients with chronic pain, such as Hix, feel they are being punished and treated like criminals, even though they have never abused their medication.
"I'm very sad for the people who came out," Hix said. "But what does that have to do with me?"
– Reporter: 541-633-2162, [email protected]