Opioids

Get rid of market barriers to appropriate pain management

Ending the nation’s opioid epidemic requires eliminating obstacles to treatment and appropriate analgesic prescribing and pain management. New policies adopted at the 2019 AMA Annual Meeting took aim at barriers established by health plans and other players in the medical system. 

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Highlights from the 2019 AMA Annual Meeting

“Physicians have a responsibility to help end the opioid epidemic, and they are taking steps: more judicious prescribing that has resulted in a dramatic decline in opioid prescriptions, enhanced education, and lobbying for policies based on clinical evidence,” said AMA President Patrice A. Harris, MD, MA, chair of the AMA Opioid Task Force. “Physicians can’t be expected to fight the epidemic with one hand tied behind their back, handicapped by policies that limit choices for patients and have no basis in science.” 

Pharmacy chains, payers and pharmacy benefit management companies “all have—to varying degrees—implemented their own policies governing physician prescribing of controlled substances as well as patients’ abilities to have a controlled substance prescription dispensed to them,” says an AMA Board of Trustees (BOT) report on the inappropriate use of Centers for Disease Control and Prevention (CDC) opioid-prescribing guidelines states. 

Existing AMA policy, as summarized in a related BOT report, “promotes patient access to comprehensive, multidisciplinary, multimodal pain care, including working with all stakeholders to promote research and develop evidence to support quality pain management. This includes promoting safe opioid prescribing and promoting a public health approach to ending the nation’s opioid epidemic.” 

Between 2013 and 2017, retail-filled opioid prescriptions decreased by 22.2%, according to research cited in the trustees’ report. 

The AMA House of Delegates (HOD) adopted new policy to: 

  • Advocate for state legislatures and other policymakers, health insurance companies and pharmaceutical benefit management companies to remove barriers, including prior authorization, to nonopioid pain care. 
  • Support amendments to opioid-restriction policies to allow for exceptions that enable physicians, when medically necessary in the physician’s judgment, to exceed statutory, regulatory or other thresholds for post-operative care and other medical procedures or conditions. 
  • Oppose health insurance company and pharmacy benefit management company utilization-management policies, including prior authorization, that restrict access to post-operative pain care, including opioid analgesics, if those policies are not based upon sound clinical evidence, data and emerging research. 

In a separate action, delegates adopted additional new policy to: 

  • Support balanced opioid-sparing policies that are not based on hard thresholds, but on patient individuality, and help ensure safe prescribing practices, minimize workflow disruption, and ensure patients have access to their medications in a timely manner, without additional, cumbersome documentation requirements. 
  • Oppose the use of “high prescriber” lists used by national pharmacy chains, pharmacy benefit management companies or health insurance companies when those lists do not provide due process and are used to blacklist physicians from writing prescriptions for controlled substances and preventing patients from having the prescription filled at their pharmacy of choice. 

The AMA was also directed to incorporate into its advocacy that clinical practice guidelines specific to cancer treatment, palliative care, and end of life care be used in lieu of the CDC’s Guideline for Prescribing Opioids for Chronic Pain as per the CDC’s clarifying recommendation. 

A separate resolution notes there is a “pain treatment gap” because pharmacy benefit plans will not cover medications that could serve as alternatives to opioids for treatment of pain. 

In adopting the resolution’s recommendation, the HOD directed the AMA to “petition the Centers for Medicare & Medicaid Services to allow reimbursement for off-label use of medications like gabapentin or lidocaine patches at the lowest co-payment tier for the indication of pain so that patients can be effectively treated for pain and decrease the number of opioid prescriptions written.” 

To address this gap, delegates directed the AMA to  

  • Advocate increased access and coverage of non-opioid treatment modalities including pharmaceutical pain care options, interventional pain management procedures, restorative therapies, behavioral therapies, physical and occupational therapy, and other evidence-based therapies recommended by the patient’s physician. 
  • Advocate for nonopioid treatment modalities being placed on the lowest cost-sharing tier for the indication of pain so that patients have increased access to evidence-based pain care as recommended by the Health and Human Services Interagency Pain Care Task Force. 
  • Encourage the manufacturers of pharmaceutical pain care options to seek U.S. Food and Drug Administration approval for additional indications related to non-opioid pain-management therapy.