A proposed rule from the U.S. Drug Enforcement Agency (DEA) may imperil hospice patients’ access to essential medications, stakeholders have indicated.
The DEA recently proposed a regulation for prescribing controlled substances via telemedicine after the COVID-19 Public Health Emergency (PHE) expires. If finalized as written, practitioners would no longer have the ability to prescribe Schedule II or Schedule III-V narcotic medications via telehealth without a prior in-person exam.
Stakeholders, such as the senior advocacy group LeadingAge, have argued that the proposal is too restrictive and would complicate patients’ ability to receive medications for pain and anxiety. This includes drugs that are frequently used in hospice and palliative care.
“We agree guardrails are needed around telehealth utilization broadly and most especially when there is a high-risk situation such as overprescribing of controlled medications,” Katy Barnett, director for home care and hospice operations and policy at LeadingAge, indicated to the DEA. “In researching this issue for members of LeadingAge, we were not able to identify any published studies that prescribing controlled medications for hospice or residents in long-term care patients is a major source of the overprescribing in our country.”
Barnett, in her public comments on the proposal, contends that hospice patients are often too sick to travel for an in-person examination and that they need to receive pain management quickly upon admission.
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 the quality of hospice care.
Other considerations include the number of hospice patients who live in remote or rural areas for whom in-person visits are even more difficult, according to Barnett.
“Clinicians do not have the ability to determine when the patient will decline and how quickly that decline will manifest. For many patients, it is a short period of time and access to pharmaceutical interventions to promote comfort is critical in these crisis periods,” Barnett wrote. “This same urgency of access often arises in patients receiving services from palliative care prescribing clinicians.”
The DEA and other agencies are in the difficult position of having to respond to the deadly opioid epidemic that has persisted for years in the United States, while also ensuring access to medications for patients in need. At times, these two objectives can appear to be at odds.
This is not the first time the hospice or medical community has sought to preserve access to these medications for patients.
Though hospice patients are exempt from U.S. Centers for Disease Control & Prevention guidelines for opioid prescribing, many clinicians and pharmacies don’t recognize the distinction — or the distinction between a guideline and a requirement.
CDC has made a number of efforts to clarify these issues, including in a letter from Senior Advisor Dr. Deborah Dowell from the National Center for Injury Prevention and Control (NCIPC).
“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,” Dowell indicated. “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.”