- - Tuesday, November 26, 2019

When it comes to ending the opioid crisis, not all Trump administration officials are on the same page. 

As a record number of Americans die from drug overdoses — fueled primarily by opioids, including heroin and fentanyl — the administration rolled out a new website to help people find addiction treatment centers.

While Kellyanne Conway and her team should be commended for making it easier to find high-quality treatment programs, other parts of the administration are failing to prevent unnecessary exposure to powerful opioids in the first place. 


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Case in point: In early November, the Centers for Medicare & Medicaid Services (CMS) — which oversees the nation’s Medicare and Medicaid programs — unveiled the final Hospital Outpatient Prospective Payment System rule, which in practice incentivizes the use of fentanyl over non-opioid alternatives.

For some surgical procedures, there are FDA-approved treatments on the market that, in addition to their other significant benefits, are safe and effective alternatives to opioid-based painkillers. In response to a congressional directive to remove financial incentives to use opioids, the CMS established a “non-opioid exclusion” that is designed to promote treatments that help patients manage pain without the downstream risk of addiction. 



The CMS’ inaction is bad news for seniors since addiction and overdose is not limited to any one demographic. According to the federal Agency for Healthcare Research and Quality (AHRQ), both the use of opioids and the complications due to opioids are rising rapidly.

In 2015, opioid-related complications caused nearly 125,000 hospitalizations and 36,000 emergency room visits for older Americans, representing a drastic 34 percent and 74 percent increase, respectively, from 2010. Meanwhile, since the misuse of prescribed opioids is a prime pathway for addiction, the 4 million seniors who AHRQ classifies as “frequent” users are particularly at risk. 

Under current Medicare policy, surgical facilities receive a single reimbursement “package” for each procedure they perform. This package is expected to cover the total cost of labor, supplies and certain medications used during the procedure with that single amount. 

Yet, opioid-based painkillers, including fentanyl which is 50-100 times more potent than morphine, are reimbursed separately and outside of any packaging under Part D. As a result, there is a strong incentive for physicians to administer fentanyl during surgery and other opioids post-operatively to patients.

Though the CMS has the authority — and a congressional mandate — to eliminate the packaging disincentives for non-opioid alternative treatments through the non-opioid exclusion, it has failed in its duty to do so. The CMS chose not to extend the non-opioid exclusion to a single product in this year’s HOPPS rule, which essentially means that seniors will be given opioids in lieu of safer and more appropriate medications simply because the reimbursement system is inadequate. 

One of the most egregious examples of this missed opportunity concerns the drug Omidria, the first and only FDA-approved medication for preventing miosis and reducing post-operative pain in patients who undergo cataracts procedures.

In a peer-reviewed study recently published in Clinical Ophthalmology, the recent past-president of the American Society of Cataract and Refractive Surgery found that Omidria lowers patient pain scores by 50 percent, while reducing the need for fentanyl during cataract surgery by nearly 80 percent.

Moreover, cataract surgery patients receiving postoperative opioids have a 60 percent increased risk of long-term opioid use. This is especially true for elderly patients who demonstrate increased sensitivity to opioids and are at greater risk of developing a dependency or addiction to them.  

Despite the peer-reviewed data and the FDA’s assessment of the drug, the CMS chose not to extend the non-opioid exclusion to Omidria. It appears that despite regulatory language to the contrary, the CMS has chosen to apply the exclusion only after there is demonstrable proof that physicians have stopped prescribing opioids because of the use of an alternative product. 

Fortunately, Congress understands the problem and is working to address it. Representatives Terri Sewell, Alabama Democrat, and David McKinley, West Virginia Republican, recently introduced the bipartisan Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act (H.R. 5172), which will require the CMS to put non-opioid treatments on par with other separately paid drugs and devices under Medicare Part B. 

The bipartisan bill will help correct CMS’ payment disincentives for practitioners to prescribe non-opioid treatment alternatives in surgical settings so that opioids are not utilized unnecessarily.

If Omidria is good enough for patients younger than 65 and our veterans — in fact, after a thorough review of the drug’s efficacy and safety, the Veterans Administration mandated that it be made available through its National Formulary to all veterans undergoing cataract surgery — why isn’t it good enough for our seniors? 

Congress should consider the bipartisan NOPAIN Act quickly. With so many Americans using, abusing and overdosing on opioids, patients can’t afford to wait.

• Brian Darling is former senior communications director and counsel for Sen. Rand Paul.

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