Missouri officials are addressing the opioid misuse epidemic by trying to reduce the number of opioid prescriptions physicians in the state provide to Medicaid patients, but the Missouri AFP and the AAFP recently collaborated to warn that the state's overly broad actions could threaten patient care.
Earlier this month, Gov. Eric Greitens announced(governor.mo.gov) that the state has started contacting physicians and other health care professionals who, officials say, "prescribe too many opioids." In 2017, the announcement stated, more than 8,000 Medicaid prescribers in the state "whose prescribing habits do not adhere to one or more Quality Indicators pertinent to the use of an opioid for management of pain" were identified.
On March 9, MO HealthNet, the state's Medicaid program, sent letters to all of the state's Medicaid prescribers(dss.mo.gov) informing them of changes to MO HealthNet's Opioid Prescription Intervention Program, including calling for opioid prescribers to adhere to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain,(www.cdc.gov) which focuses on pain lasting longer than three months.
Prescribers "whose prescribing activity results in flagging one or more Quality Indicators" related to opioid prescribing would receive additional communication regarding their specific activity, the letter noted. Those who fail to adequately explain their prescribing activity within 20 days of receiving a second letter from the state would be referred to their state licensing board and the Missouri Department of Social Services.
In response, the AAFP collaborated with the Missouri AFP on a March 13 letter(www.mo-afp.org) addressed to Greitens and the respective directors of the state departments of Health and Senior Services, Social Services, and Mental Health that also copied the Missouri Senate and House of Representatives. The letter, signed by Missouri AFP President Mark Schabbing, M.D., of Perryville, pointed out that the guideline was never meant to be a law, and that the state's drastic action could harm patients who depend on prescription medication.
Moreover, the letter notes that many of the recommendations in the CDC guideline are based on insufficient evidence and that "the guideline did not meet the National Academy of Medicine's standards for clinical practice guidelines."
Although family physicians do consult the guideline, treatment should be based on shared decision-making between physician and patient using all available evidence.
"If the guideline were to be implemented as a rule, regulation or law, physician discretion and decision-making would be undermined and patient care would suffer," the letter stated.
The letter highlighted other consequences that could occur as a result of the state's action, especially considering the significant barriers to nonpharmacologic treatment options for pain in public and private health insurance plans.
"We fear that this would cause significant disruption to care for patients who are currently receiving long-term chronic pain treatment," the letter stated. "Patients who have an established treatment plan with their physician should not have this disrupted due to a change in law."
State officials used the Medicaid database to track prescription patterns, reporting that 1.2 million prescriptions were given to Medicaid patients. But the Missouri AFP noted that opioid prescribing is decreasing for most physicians even as it is increasing among advanced practice registered nurses and physician assistants.
Helping patients move away from opioid dependence requires long-term treatment, and the letter cautioned that Missouri's health care system does not have the capacity to treat a high volume of patients who are suddenly cut off from opioid treatment.
"While decreasing access to opioids is critical to tackling the opioid epidemic, it is imperative that treatment regimens are supported, helping to wean patients from misuse," the letter stated. "The opioid epidemic is devastating to our state and the patients we treat every day. We are on the same team."
Related AAFP News Coverage
CDC Clarifies Opioid Guideline Dosage Thresholds
Missouri AFP: MoHealthNet Opioid Prevention Intervention(www.mo-afp.org)