Opioid Policy:Hospice in the Crossfire

Obtaining necessary pain medications for terminally ill patients is becoming more complicated for hospice and palliative care providers. The advocacy group Healthcare Professionals for Patients in Pain (HP3) raised the alarm on potential misapplication of opioid prescription guidelines throughout the health care continuum in an open letter to policymakers.

Pain management is a cornerstone of hospice care and can have a substantial impact on patient and family satisfaction. A 2014 study found patients and families view pain and symptom management as their top priority related to quality of hospice care. With consumers and referral organizations paying increased attention to publicly reported quality data, dissatisfaction with pain treatment can hurt an organization’s bottom line.

HP3’s letter to the U.S. Centers for Disease Control and Prevention (CDC) centered on the need to balance efforts to reduce overdoses and addiction with patients’ legitimate pain management needs. Though they praised aspects of the CDC’s 2016 Guidelines for Prescribing Opioids for Chronic Pain, HP3 said that misunderstanding of its tenets was impeding patients’ access to pain therapies.

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Many clinicians, insurers, and pharmacies have interpreted the guidelines as requirements rather than recommendations, according to HP3. Some prescribers are also concerned that deviation from the guidelines could expose them to liability or impact their performance on publicly reported quality measures.

“I do receive word of patients with hospice and palliative care needs being caught in the crossfire,” said Stefan Kertesz, M.D., professor of Medicine, University of Alabama at Birmingham, a signatory to the HP3 letter. “Many are living with terminal conditions and subject to restrictions based on hospital policies, pharmacy policies, payer policies, along with fear by the clinicians who take care of them.”

The intent of the guidelines is to improve communication between clinicians and patients about opioids benefits and risks, provide safer, more effective care for patients with chronic pain, and help reduce opioid use disorder and overdose, according to the CDC. The guidelines do not apply to cancer patients, palliative care patients, or patients at the end-of-life, but pharmacies and insurance companies do not always recognize this distinction.

A pivotal factor is the guidelines’ recommendation to reduce opioid dosage to 90 morphine milligram equivalents (MME), as well as limits on how long a patient can receive opioid therapy. Many insurers have adjusted their payment policies to only cover opioid prescriptions that adhere to the guidelines, often without providing coverage for non-opioid alternatives. Meanwhile, numerous pharmacies have begun requiring a pharmacist review of the medical chart or a written medication tapering plan prior to filling a prescription. These processes and paperwork can delay terminally ill patients’ access to medications.

“Many of my patients have encountered misapplication of the CDC guidelines, usually from their health insurers or pharmacies,” Chad Kollas, M.D., a palliative care physician at the Orlando Health-University of Florida Health Cancer Center told Hospice News. “I also receive letters from health insurers citing the CDC’s [morphine equivalent daily dose] not as a guideline, but as an absolute cut-off for dosing. When given the opportunity, I clarify that both the CDC Guideline and AMA policy support individualized opioid dosing.”

Due to such misperceptions, patients have endured unnecessary suffering and medical deterioration, sought avoidable hospitalizations, and in some cases turned to illicit substances or suicide, according to HP3.

Health care providers are concerned. Nearly two thirds of health care providers said they feared prosecution related to opioid prescriptions, according to a March survey by the Pain News Network. One in four respondents said that at least one of their patients had committed suicide due to pain since the CDC released the guidelines in 2016.

“In hospice pain management is essential to what we do,” said Dan Peterson, CEO of the Arizona-based hospice Valor Health. “We have to discern which patients need that care and make sure they can get their medications quickly and effectively, while ensuring that the narcotics we use are only going to the patients who need them, when they need them.”