Re­duc­ing dosages of opi­oids

Colorado’s Med­i­caid pro­gram is try­ing to com­bat ad­dic­tion and over­doses.

The Denver Post - - NEWS - By John In­gold

Colorado’s Med­i­caid pro­gram is re­duc­ing the amount of opi­oid painkillers it al­lows its re­cip­i­ents to re­ceive, part of a grow­ing cam­paign to re­strict how many of the highly ad­dic­tive drugs are in cir­cu­la­tion.

The new pol­icy, an­nounced this month, will roll out in two phases. The first, which goes into place in Au­gust, ap­plies to Med­i­caid re­cip­i­ents who are pre­scribed opi­oids for the first time in at least a year. The pol­icy will limit those pa­tients to re­ceiv­ing only a seven-day sup­ply to start, with two ad­di­tional one-week re­fills pos­si­ble if the pa­tient re­quests them. An­other re­fill re­quest be­yond that will re­quire ad­di­tional scru­tiny.

Dr. Judy Zerzan, the chief med­i­cal of­fi­cer for Colorado’s Depart­ment of Health Care Pol­icy and Fi­nanc­ing, which ad­min­is­ters Med­i­caid in the state, said the goal of this first phase is to pre­vent new pa­tients from be­com­ing hooked on pain pills.

The sec­ond phase will re­duce the to­tal dosage of opi­oids that all Med­i­caid pa­tients can re­ceive.

Cur­rently, Med­i­caid won’t pay for re­cip­i­ents to re­ceive more than 300 mor­phine mil­ligram equiv­a­lents, or MME, per day. The MME mea­sure­ment helps doc­tors stan­dard­ize doses across opi­oids of vary­ing po­tency.

The new pol­icy will re­duce that max­i­mum amount to 250 MME per day. Zerzan said the state will likely look at re­duc­ing that limit fur­ther but wants to en­sure that pa­tients cur­rently on a high dose are weaned down slowly to avoid pain spikes or prob­lems from with­drawal.

The amount is still well above fed­eral guide­lines put in place last year. The Cen­ters for Dis­ease Con­trol and Preven­tion warn doc­tors about pre­scrib­ing opi­oid doses above 90 MME per day. Colorado’s med­i­cal reg­u­la­tors have en­cour­aged all doc­tors to keep pre­scrip­tions be­low 120 MME per day.

But chronic pain pa­tients in Colorado and other states have said such lim­i­ta­tions block ac­cess to im­por­tant med­i­ca­tions they need to live nor­mal lives. And the new Med­i­caid poli­cies will have ex­emp­tions for peo­ple re­ceiv­ing hos­pice or pal­lia­tive care or who are can­cer pa­tients.

Marc Wil­liams, a spokesman for the pro­gram, said doc­tors can also call a Med­i­caid spe­cial­ist if they be­lieve other pa­tients re­quire more than 250 MME per day.

“Ev­ery pa­tient has in­di­vid­ual med­i­cal needs,” he said, “and they’ll be eval­u­ated on a case-by­case ba­sis.”

Zerzan said med­i­cal re­search shows opi­oids may reach max­i­mum ef­fi­cacy for even the most se­vere pain at dosages as low as 90 MME,

and she said the state will en­cour­age doc­tors to pur­sue al­ter­nate med­i­ca­tions or pain-man­age­ment prac­tices to try to pre­vent pa­tients with chronic pain from de­vel­op­ing a tol­er­ance to opi­oids that re­quires higher amounts. Colorado’s Med­i­caid pro­gram two years ago in­creased how much it pays for out­pa­tient phys­i­cal ther­apy, in part to en­cour­age its use more widely for pain man­age­ment.

Zerzan said she hopes the new pol­icy will also re­duce over­doses and deaths. When re­searchers an­a­lyzed the state’s Med­i­caid data, she said, they found pa­tients were more likely to over­dose if they were pre­scribed over 300 MME per day.

“There was def­i­nitely a trend,” she said, “that the more opi­ates you were on, the greater your risk of death.”

Med­i­caid, which is a shared state and fed­eral pro­gram for peo­ple with low in­comes or dis­abil­i­ties, cov­ers more than one out of ev­ery five peo­ple in Colorado.

Wil­liams said, as of late last year, there were 200 Med­i­caid mem­bers in the state re­ceiv­ing 300 MME per day or more.

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