CDC Guidelines and Legislative Limitations on Opioid Prescriptions Negatively Impact Hospice and Palliative Care Patients

FierceHealthcare publishes an article authored by our colleague Terri Maxwell Ph.D., APRN, Chief Clinical Officer of Turn-Key Health, which describes the issues surrounding restrictions on opioid prescribing which have resulted in unintended consequences for patients with serious or advanced illness.

“When Nightmares Come True” describes the issues surrounding restrictions on opioid prescribing that are resulting in unintended consequences for patients with serious or advanced illness.

Dr. Maxwell first presented her concerns about potential adverse consequences for hospice and palliative care patients in 2016 with the publication of “CDC opioid guidelines raise alarms among hospice and palliative healthcare providers,” and now describes ways in which her predictions have become a reality.

Below are some of the highlights of the article that raise a red flag for clinicians – and patients – in the hospice or palliative care space.

Consequence of the CDC Guidelines and Regulatory Changes

Maxwell points to the barriers that face some hospice and palliative care patients who are trying to access medications and others faced by prescribers.  She says that while CDC guidelines are advisory, not mandatory, they are having a chilling effect on prescribing among physicians, insurers and other government agencies.

Problems began surfacing in 2018 when physicians across the country began reporting that payers were using the guidelines to deny opioid prescriptions, or increasing the use of prior authorizations, even for patients suffering from pain stemming from cancer treatment, end-of-life care and other conditions.  Unfortunately, these actions place patients at risk of inadequate pain relief

The situation is spilling over to some pharmacies that are unwilling to stock the drugs, especially at high doses. Patients also report being treated like substance abusers when picking up prescriptions at their local pharmacy.

Overreaction to Legislation

CDC clarification of its policy and other published reactions in high profile journals are duly noted, although none have specifically mentioned concerns about misapplication of the guidelines for patients receiving hospice or palliative care.

While controlled substance policies usually exempt hospice and palliative care patients, they don’t always protect them from restrictive practices by payers or pharmacies — some of which go so far as to refuse to fill or cover analgesic prescriptions.  Furthermore, determining when patients are “palliative” and “end of life” can be challenging and often not well defined.

Further compounding the situation, numerous doctors have voluntarily limited the number of opioid prescriptions they write for patients and some refuse to prescribe any opioids due to fear of being disciplined for overprescribing or because they don’t want to deal with the increasing burdens associated with mitigating risk.

Here are some additional concerns specific to hospice and palliative care:

  • Physicians are under increasing scrutiny for prescribing opioids and may be especially concerned about prescribing at doses higher than the guidelines recommend – which are low for many patients with cancer and those at the end of life.
  • The guidelines include dose recommendations that are not realistic for many patients with cancer or those requiring palliative or hospice care.
  • Some states are now mandating the placement of naloxone in the home based upon dose or days’ supply with no exceptions for hospice patients.
  • Hospice clinicians are encountering opiophobia among patients and caregivers resulting in unmanaged pain at the end of life.

Calls for Proactive Steps

Dr. Maxwell says now is the time for hospice and palliative care clinicians to work closely with hospice and other pharmacy providers, state pharmacy boards and other regulators to minimize restrictive policies and to combat opiophobia affecting patients, prescribers and payers.

Enclara Pharmacia is a leading advocate for not allowing reversals in progress made over the last two decades to effectively use opioids to treat pain in end-of-life care. In 2018, Enclara launched our Opioid Stewardship Program to help our partners respond to the unique challenges the opioid crisis poses to the hospice community. The program includes tools, training and resources to support safe and responsible opioid use in hospice while promoting best practices to ensure safe and effective use of opioids in the home and other settings.

To view the article, please click here.