Medicare to More Closely Scrutinize Opioid Prescribing

Health Editor Note: Let's face it! If you need pain relief that goes beyond what you can buy over the counter, you should be able to have the drug that offers that relief prescribed for you. Pain is a very serious matter and will affect how you can perform your daily activities of life. You may have chronic arthritis, back pain, head aches, etc. and these all cause pain/discomfort which will decrease your ability to enjoy life. Because others have received (legally or illegally) and used opioids for recreational use (not for pain but to get high), you might feel as though you are jumping through hoops that constantly keep changing or treading on a very high wire in order to receive medications that will relieve some or all (if you are lucky) of your pain. You, of course, have done nothing wrong and are only seeking the medical treatment that you have a right to receive. Level of pain is taken so seriously by the medical profession that is now known as the fifth vital sign. Blood pressure, respiratory rate, heart rate, and temperature are the other four vital signs that demonstrate a relative picture of a person's health at any given time.. You will (or should) be asked, if you mention having pain, to rate your pain from 1 to 10 with 1 being the least amount of pain you have felt and 10 being the worst pain. Bottom line, if you are having pain you should receive relief but get use to the fact that there will be measures added to try to filter out/stop those who abuse the pain relief system. And, do I want to go into discussing doctors who prescribe unnecessary pain medications for fee or favors they will receive from the recipient? Not really........ At least not here.


Medicare will more closely scrutinize opioid prescribing and dispensing beginning in 2019, following through on a proposal outlined in a major 2016 law aimed at addressing the opioid crisis.

The Comprehensive Addiction and Recovery Act of 2016 (CARA) directed the federal health program to identify Medicare beneficiaries at risk for substance misuse and require those found to be inappropriately using opioids to receive prescriptions from a single clinician and a single pharmacy.

This type of “lock-in” program has been used by state Medicaid programs since the 1970s. Its inclusion in CARA was supported by consumer advocates, pharmacy organizations, and physician groups, such as the American Medical Association (AMA), but with caveats.

The Centers for Medicare & Medicaid Services (CMS) has now proposed the rules to implement the lock-in. At press time, the AMA and pharmacy groups said they were still studying the regulations and referred Medscape Medical News to comments made after the passage of CARA. CMS is accepting comments on the new regulations through January 16, 2018.

The agency believes that the program could not only help prevent opioid dependency in beneficiaries but would save Medicare some $13 million in 2019, owing to fewer prescriptions. The cost will be $2.8 million per year, which will primarily be borne by Part D drug plans.

Essentially, the rules build on Part D prescription drug plans’ existing drug utilization review (DUR) programs. In 2013, CMS instituted an opioid overuse policy that required Part D plans to monitor opioid prescribing to help flag inappropriate use.

As a result, from 2011 (before the new policy) to 2016, high-risk opioid use declined by 61% (representing more than 17,800 beneficiaries), even as Part D enrollment increased 38% ― from 31.5 million to 43.6 million beneficiaries during the same period, said CMS in the proposed rules.

The CARA lock-in program, which would require additional steps by Part D plans, would be voluntary.

Cynthia Reilly, project director of the substance use prevention and treatment initiative at the Pew Charitable Trusts, told Medscape Medical News that she believes Part D drug plans will be interested in participating in the new Medicare lock-in program, because many of them now take part in opioid-targeted utilization review.

“This legislation will help save lives,” said Mark Merritt, president and CEO of the Pharmaceutical Care Management Association in a statement after the passage of CARA.

“The key to curbing ‘drugstore shopping’ for controlled substances is to stop improper prescriptions from being filled at the pharmacy counter in the first place,” said Merritt, whose organization represents pharmacy benefit management plans that administer drug benefits for Medicare Part D plans, employers, and others.

The AMA expressed some concern that a note from the plan might create confusion and harm the patient-physician relationship.

“Notices sent by a Part D sponsor to patients or patients’ caregivers who have not discussed the drug risks with their physicians will interfere with patient-physician relationships, harm trust, and potentially lead patients to abruptly discontinue therapy,” said AMA Executive Vice President James Madara, MD, in a letter to CMS in November 2016.

“Patients with substance use disorders need to be referred for treatment. There needs to be hands-on coordination of patient care, which a letter from a Part D plan simply cannot accomplish,” he said.

After reviewing the case with the prescriber, the Part D plan can move to limit that beneficiary’s access to opioids by locking them in to a single prescriber and a single pharmacy, but not without the agreement of the prescriber. The plan also has to notify the beneficiary that he or she is being put into the program.

Beneficiaries can appeal their at-risk designation and their placement into a lock-in program.
Reilly said the regulation does a good job of establishing strong beneficiary protections. It provides exceptions to the one-pharmacy rule ― for instance, in situations in which geography or weather is a factor.

But, she said, some beneficiaries who could be steered clear of opioid dependency still might fall through the cracks. Some individuals with substance use disorders not only visit multiple pharmacies but also visit emergency departments, which will not be tracked by the Part D plans.

Another red flag for a patient’s being at risk is that patient’s receiving multiple prescriptions for controlled substances that are in the same therapeutic class. Those prescriptions will not be flagged under the new program.

“By looking at either more criteria or more clinically complex criteria, we can do a better job of identifying those patients who are at greatest risk,” said Reilly.

The regulations also do not direct the plans to refer patients who may have substance use disorders to treatment. That’s “something we should strive for,” she said.

Medscape Medical News © 2017 Cite this article: Medicare to More Closely Scrutinize Opioid Prescribing – Medscape – Dec 08, 2017.

Carol graduated from Riverside White Cross School of Nursing in Columbus, Ohio and received her diploma as a registered nurse. She attended Bowling Green State University where she received a Bachelor of Arts Degree in History and Literature. She attended the University of Toledo, College of Nursing, and received a Master’s of Nursing Science Degree as an Educator.

She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen – two daughters-in-law; Suzy and Katie – two granddaughters; Isabella Marianna and Zoe Olivia – and one grandson, Alexander Paul. She also shares her life with husband Gordon Duff, many cats, two rescue pups, and two guinea pigs.

Carol’s Archives 2009-2013

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  1. Here is a very enlightening interview of the late Abram Hoffer, M.D., Ph.D. (1917-2009) at age 91 at this link with a brief quote:

    From the Townsend Letter
    November 2009

    Order this issue!
    Abram Hoffer, MD, PhD
    interview by Andrew W. Saul

    Online publication only
    “Some years ago, as I sat at lunch with Dr. Abram Hoffer, I took some vitamin pills. Dr. Hoffer leaned over towards me and said, “You know, you’re going to live a lot longer if you take those.” As I looked at him, he added, “I guarantee it. If you don’t, come back and tell me.”

    So said the founding father of orthomolecular medicine.

    It was nearly 60 years ago when Abram Hoffer and his colleagues began curing schizophrenia with niacin. While some physicians are still waiting, those who have used niacin with patients and families know the immense practical value of what Dr. Hoffer discovered. Abram Hoffer’s life has not merely changed the face of psychiatry. He has changed the course of medicine for all time. His 30 books, 600 scientific papers, and thousands of cured patients have yet to convince orthodox medicine. Dr. Hoffer has said that it takes about two generations before a truly new medical idea is accepted. Perhaps in the case of megavitamin therapy, maybe it is three generations. Great ideas in medicine, or anywhere else, are never self-evident…..”

  2. I am not mistaken, Peter. Ian found one of my comments in the trash and he did not put it there. Someone did. Something similar could be happening to Eduardo. Do you remember after the April false flag gas attack in Syria, when VT was hacked by the Feds? Check Gordon’s files, there’s probably something there about it. I remember it clearly because the site shut down completely while I was typing a comment and it was glitchy for the next couple days. I’m not blaming the staff for anything, but $h!t happens around here.

    Also, I responded to your question here

  3. It should be standard knowledge that buying opium from Afghanistan would currently be cheaper than buying from countries who legally sell it. They are not allowed, so they have to sell black market which is always cheaper. Pharma buys opium and Afghanistan stuff is good. High grade and cheap. Grown by farmers with excellent weaponry protecting them. Cheap because they are under siege, and oh what a coincidence, for the longest war in US history just at the same time as the highest rate of opium addiction. What a coincidence.
    We have wedding cakes being deliberated in our Supreme Court while {Pharma and Street sales} of opium in the US are at the highest rate in history. In the fog of another “questionable war” involving American soldiers. In a land known for opium production ??? And the same group who wants the war is profiting ?
    What a coincidence.

    • Question: If I reduce my cost of opium by 75 % at the same time I lobby for medications containing it to be freely distributed to the soldiers I sent in (very patriotic sales) to seize the land and poppies, do I make a good profit ? And how much more if I tax those same soldiers 30 to 50 % on their wages ? And again when I tax the people to pay for it ? While groping their women.

  4. In 1985, I was involved in a motor vehicle accident. A truck struck the car behind me, which hit my car. Chiropractic treatment of a resulting back injury made it worse, and in fact caused compression fractures of two vertebrae (T10-11). Over the years, because doctors kept diagnosing my complaints of back pain as “stress and anxiety”, the problem(s) got much worse. I have lived with chronic pain for more than thirty years, and have seen pain management practices go through three cycles of: untreated pain-> opioids prescribed-> opioid “crisis” -> opioids no longer prescribed -> untreated pain. This 2017 opioid “crisis” will pass, but many patients will unnecessarily suffer greatly before rational pain management begins again.

    The Veterans Administration, in order to get funding, recently adopted CDC guidelines for pain management that required almost all veterans who were on opioids to be weaned off opioids and referred for other means and methods of treating pain. I have gone through all of the VA’s suggested pain management strategies – exercise / yoga, NSAIDS, psychiatric / psychological counseling – at least twice, and NONE of them provided as much pain relief as a moderate dose of opioids. Because of chronic pain, and ineffective pain mangement practices, it was only within the last half dozen years, after finally being assigned to a VA doctor who took the time to really listened, that I have been relatively happy and functional. He retired, and my latest provider informed me I don’t need the meds that have made my life liveable, so I am in the process of being “weaned”.

    I honestly don’t know if I can live with the level of pain that is already returning to my life. It will not surprise me at all if the current twenty two veteran suicides per day increases by several per day, driven by veterans who simply cannot live with the chronic pain. The CDC guidelines were, apparently, developed with the help of a group of doctors who run addiction treatment clinics, one of the recommended treatments for veterans being weaned off opioids.

    On the topic of “pain scales”, I have long felt the scales – there are several – were easily abused. I have a neighbor who always tells his doctor his pain (knees) is at 10 on a 1-10 scale. “What would you say if your leg were cut off” I ask him. “Well, that would be an 11…” he says. A good article, with some good comments, here:

    • “to really listened” s/b “to really listen”

      It would be great if there was way to edit comments, at least for a few minutes after submission. Just a thought / suggestion.

    • Carnaptious, thanks for sharing the story. One of the great aspects of this comment board is the inability to edit and freedom from unreasonable censorship. Once it is there, it is time stamped. Editing makes for speculative questioning. Fresh is always better, who cares about imperfections. Your message is quite clear.

  5. “Pain and treatments for pain is very complicated subject” should be “Pain and treatments for pain are very complicated subjects”.

    • Please delete this comment and the one above that appeared in the wrong place because I’m still getting accustomed to the new VT “look and feel”.

  6. I’m not sure there is a character max of 1500 anymore. I never counted the characters, but I’m sure that list of Trump’s tribal masters that I posted the other day is closer to a million characters, (not quite) and it’s still there. I honestly think VT gets broke into sometimes and the perps mess with people’s accounts. A couple years ago I signed in with my name and password, but I was logged in as a user named LZ, and the comment I made was registered in his name. I told him about it and he said the same thing happened to him with another user.

  7. I wish I could get some codeine cough syrup instead of being awake half the night with a dry, hacking cough, but everyone is now afraid to prescribe it. Never had any side effects from it or cravings for it after a one week supply was gone.

    • The only thing I crave is not having a cough so bad that it causes sleep deprivation. Codeine cough syrup for a few days until the underlying infection clears up is hardly abuse – in the past the longest I ever used it was 6 days and I ended up tossing out the last day’s dosage or so because I no longer needed it.

      I took the narcotics I was given after oral surgery for wisdom tooth removal for one day – stuff made me feel sick so I tossed it in the trash and just took high-dose ibuprofen for the next few days.

  8. Amelius, Marijuana has also been used in patients with Alzheimer’s plaques in the brain, since the THC can prevent an enzyme called acetylcholinesterase from accelerating the formation of “Alzheimer’s plaques” in the brain, and also prevent protein clumps that can interfere with cognition and memory. Also for multiple sclerosis where it helps ease the pain in the arms and legs from muscle contractions. It can be used for glaucoma since it helps to reduce pressure inside the eye. Arthritis – Marijuana had been proved to be helpful for many types of chronic pain conditions such as arthritis. Marijuana helps improve the effectiveness of drug therapy for hepatitis C by relieving some of the side effects (loss of appetite, depression, nausea, muscle aches associated with the drug therapy. For cancer, HIV/AIDS and chemotherapy the active ingredients in marijuana relieve nausea and vomiting and increase appetite in people with cancer and AIDS. Carol

  9. The DEA lists India, Turkey, and Australia as currently the 3 countries legally producing opium. I do wonder if the Afghanistan opium is seen as a boon for the pharms like the Syrian oil.

  10. I’m from Canada and a few of my friends are fatally hooked on prescription opioids and even fentanyl. Here’s something I find appalling. My stepmother has suffered from different ailments, including but not limited to fibromyalgia. She’s tried all the dangerous pharmaceuticals with their extensive lists of harmful side effects. After about 18 years of trying everything with no lasting positive results, she decided to inquire about medical marijuana. For the first time in 18 years, she was expected to go infront of a committee and explain to them why she should be allowed to acquire medical marijuana.

    Meanwhile, my stepmothers 18 year old niece had her wisdom teeth removed and they gave her a prescription for Oxycodone, no questions asked. It was standard procedure. I asked her to tell me the name of the scumbag who prescribed her the highly addictive and deadly drug that is killing my friends, so that I could go and have a “word” with him, but she intelligently refused.

    I find it absolutely insane and disgusting that a young person is prescribed highly addictive and extremely deadly opiates like OxyCodone for something as minor as the removal of wisdom teeth, while a woman who has tried everything while suffering for 18 years, is required to stand infront of a committee to obtain a substance that has never directly killed anyone and has never been conclusively proven to be habit forming…

    On the bright side, my stepmother was approved for medical marijuana and after 6 weeks of taking it, she has gained her life back. No, I’m not exaggerating. Not even a little. She spent 18 years staying up all night and sleeping on the couch for an hour here and there. She could not even climb the stairs to get to her bed. She was visibly miserable most of the time and constantly complained of being in pain. After just 6 weeks of taking CBD oils, she is now following a regular sleeping pattern; accomplishing more around the house in one day than she used to accomplish in a whole month; her personality is noticeably much more positive and upbeat; she hasn’t complained of being in pain once, and most importantly, she is happy again.

    I also have a cousin who has suffered from epilepsy for decades. Under the direct order of her doctor, she spent 20 years on a dangerous drug that she was only supposed to take for a maximum of 5 years. This drug didn’t even work, as she was still having between 5-15 seizures every day. She couldn’t even live her life. After 9 months of taking CBD oil, she has only had a handful of seizures and is totally off the dangerous drugs that weren’t working. She too has gained her life back.

    • Johnny America,

      Thank you for this reply, much appreciated. I no longer tolerate junkies in my life, either. They have lost themselves and no one can tell them anything. The person you once knew is gone. I’ve tried to help in the past, but it always ended with them trying to manipulate me.

      You’re absolutely right about alcohol giving rise to criminal gangs. Criminal empires were built on prohibition. The Bronfman tribe from Canada played a big role in all that, if I’m not mistaken.

      My stepMom never held any prejudices against marijuana. I’ve been growing personal amounts and smoking it for years and it never bothered her. One time, heavily armed government thugs came to our place with a helicopter and blacked out SUV’s, just to get a few plants! There was no telling them to GTFO, they didn’t even need a warrant. They have a list of locations and the government rubber stamps it.

      Anyways, smoking it never did anything for her. It was CBD oil that she needed and she wasn’t confident she could get a consistent supply without a prescription. Her doctor held prejudices against cannabis and made her jump through hoops to get it. You can get CBD oil from a dispensary without a prescription, but dispensaries are still technically illegal here and they get raided fairly often. She gets it from a licensed producer now, where it’s consistently made in large quantities and analyzed for chemical and microbial contaminants. I tried some pink kush from a licensed producer, and it was actually awesome.

      I’ve never even thought about being persecuted for having a marijuana prescription. That is crazy! I’m going to have to look into how that’s effecting Canadians too. I’m taking a university course right now on marijuana plant production and facility management, learning about all the different regulations, restrictions and responsibilities, and there are MANY. But, it’s something I might look to pursue professionally.

      Getting back to the gym will be my new years resolution. I actually followed through on the last one I made, and I do want to get back in there. I just have to make time.

    • Oh ya, I forgot to mention Canada’s “clean injection sites” where junkies can go and shoot up. These sites even stock what is referred to as “medical grade heroin” paid for by taxpayers and given to the real hardcore junkies who can’t afford to support their deadly habit. In Vancouver, 1 out of every 3 emergency calls to fire and rescue are opiate overdoses. More than 150 per week.

    • I live in Oregon, where medical marijuana (MMJ) has been legal since 1996, and recreational marijuana (RMJ) legal since late in 2016. Back in 1996, one of the major reasons for making MMJ available was that it would enable poor people to grow their own pain medication. But growing top quality MJ isn’t easy, and doctors were even less willing to prescribe MMJ than pain meds. MMJ cards were rare until about 2003-04 when THCF began to bring in MMJ friendly doctors who traveled around the state signing documents. But that ran afoul of the requirement that a patient’s PCP was required to provide a MMJ prescription, so new rules had to be developed.

      Long story short… every few months now, Oregon’s bureaucrats rewrite MMJ/RMJ growing regulations, making it more and more difficult for poor patients to grow their own, or have someone grow it for them, the original reason for MMJ. I have been a poverty stricken MMJ cardholder since 2005, and through an odd series of events I now have access to a great source, and can get whatever I need for almost nothing, but that is far from common. Many MMJ patients need hundreds of dollars worth of MMJ each month, and medicare doesn’t cover it. Some of them go to doctors for an opioid prescription, and sell those pills for enough to buy the MMJ!

      RMJ restrictions on growing are even more onerous, and it appears to many people here that the state legislature, and the bureaucrats, are gradually moving towards making it so difficult and complicated to keep up with restrictions that only corporations will be able and willing to comply. Unsurprisingly, some folks have decided to go back to black market marijuana (BMJ) growing and selling. The upside is that BMJ is much cheaper than it was ten or twenty years ago. The downside is that it’s illegal, and could get BMJ growers put in jail. The sad truth is that substances that make people feel good – regardless of underlying pain or pathologies – will always be prone to abuse. That’s true of MMJ, RMJ, BMJ, opioids, many other drugs, and alcohol.

      MMJ / RMJ / BMJ have helped many people with chronic pain, and or illness, both medical (epilepsy, cancer) and psychological (depression, anxiety). However, it is not a panacea for all that ails us, as some people believe. There are many valid uses for MJ, and many circumstances in which MJ is just one part of a more complex tratemnt plan.

      Pain and treatments for pain is very complicated subject Mrs. Duff. Thanks for having the courage to broach it.

    • “Pain and treatments for pain is very complicated subject” should be “Pain and treatments for pain are very complicated subjects”.

    • Johnny America,

      Yes indeed, I am one of those mysterious figures from the shadowy underworld of cannabis connoisseurs and cultivators! Jump in your car and come on up here, company is always welcome at our place.

      I wouldn’t say you were wrong about my stepMom, you just didn’t have all the details. I totally agree that oils and extracts are best from pharmaceutical grade labs. The process of extraction often involves the use of chemical solvents like butane or isopropyl, and licensed pharmaceutical grade labs perform analytical tests to ensure their product is safe for human consumption. Basement dwellers are most likely not qualified to perform these tests themselves and would likely have to outsource analytical testing. This can be expensive, so it is unlikely that the basement dweller would have his product tested.

      The raid was totally overkill. It appeared as though they were after Joaquin “El Chapo” Guzman, himself. The operation must have cost the government a hundred thousand dollars, to remove a couple pounds of marijuana. Heroes I tell you! Heroes.

      You raise an interesting point about the U.N./NATO perspective. I’ll have to look into that, too.

      I’m not sure about access to Canadian Veterans specifically, but some Canadian insurance companies offer coverage for medical marijuana, while others are still on the fence. However, under the current regulations (ACMPR), registered patients can apply for a permit to grow their own, or designate someone to produce it for them. This was not permitted under the previous set of regulations, but the federal government was taken to task. In short, it was determined that restricting access to medicine was unconstitutional. The federal government ruled that it did not have the authority to force Canadians to choose between their health and their liberty, so patients can apply to grow their own.

      The Canadian government hopes to have cannabis legalized for both medicinal and recreational use by July, 2018. When this happens there will be no need for a prescription, and doctor’s prejudice will not hinder people from seeing if this can work for them.

      No need to laugh at yourself, friend. I’ve found your comments very informative.

    • Carnaptious, you raise a lot of important points. It seems that the medical marijuana industry in America is solely focused on corporate profit margins, not unlike every other industry. We are now on our third set of government regulations in Canada. The first set allowed patients to grow their own. The second set prohibited that action. Then, as mentioned in my above comment to Johnny America, the Canadian government was taken to task on this, and the government itself ended up ruling that it does not have the authority to force Canadians to choose between their health and their liberty. Now, the third and present set of regulations (ACMPR) allows patients to obtain a permit to grow their own.

      You mentioned people selling prescription opiates to pay for medical marijuana. I know people here who buy marijuana on the street and sell it, or trade it for opioids.

    • You’re welcome, Johnny.

      We’ll have to wait and see how Canada’s system works once it’s up and running. It looks Ok on paper, but we won’t know until we see it in operation.

      Thanks for the link on the U.N. barrier to legalization. I haven’t read it yet, but I will as soon as I have time. Israel is at the forefront of medical marijuana research too. I’m not thrilled about it, but I’m not going to throw the baby out with the bath water…

      The feds brought in a helicopter and some SUV’s filled with armed thugs to do a job that two police officers could have easily handled in a couple hours. Lol

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