In response to reports of misapplication of opioid prescribing guidelines, the US Centers for Disease Control and Prevention (CDC) has clarified that those guidelines do not apply to end-of-life care, palliative care, or treatment of pain related to cancer.
The guidelines, issued in 2016, recommends nonopioid approaches including physical therapy as a preferred first-line treatment for some—but not all—types of chronic pain, as well as dosage and pharmacy review requirements.
Common misunderstandings about the guidelines relate to their recommendation to reduce opioid dosage to 90 morphine milligram equivalents (MME), as well as limits on how long a patient can receive opioid therapy. Payor and pharmacy policies do not always recognize the exemptions for hospice and palliative care, resulting in delayed or inadequate access to medications for those patients.
A 2014 study found patients and families view pain and symptom management as their top priority related to quality of hospice care. Deficiencies in pain management can affect a hospice’s publicly reported quality and patient and family satisfaction scores, which prospective referral partners and patients are using increasingly when choosing a hospice.
“The guideline was developed to provide recommendations for primary care physicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care,” Deborah Dowell, MD, MPH, senior medical advisor and chief medical officer at the National Center for Injury Prevention and Control (NCIPC), wrote in a clarification letter. “Because of the unique therapeutic goals, and balance of risks and benefits with opioid therapy in such care, clinical practice guidelines specific to cancer treatment, palliative care, and end-of-life care should be used to guide treatment and reimbursement decisions regarding use of opioids as part of pain control in these circumstances.”
CDC is responding to concerns voiced by health care industry organizations including the National Comprehensive Care Network, the American Society of Clinical Oncology, and the American Society of Hematology that some payers were including hospice and other exempt services in policies denying payments for prescriptions outside the scope of the CDC guidelines.
The clarification does not represent a policy change from CDC; the exemptions have existed since they were released in 2016. The agency’s intent is to raise awareness of those exemptions to resolve the payor and pharmacy issues adversely affecting patients.
“The guideline is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management,” Dowell writes. “Rather, the guideline is intended to ensure that clinicians and patients consider all safe and effective treatment options.”