What Are Medicare Opioid Guidelines?

What Are Medicare Opioid Guidelines?


The opioid epidemic affects people of all ages. The Centers for Disease Control and Prevention (CDC) estimates that 130 Americans die from an opioid overdose every day. While drugs like heroin and illicitly-manufactured fentanyl account for the majority of cases, 35% of deaths were attributable to prescription opioids like methadone, hydrocodone, and oxycodone in 2017.

Interestingly, that same year, there was a 10.5% increase in opioid-related deaths due to prescription opioids for people 65 years and older (i.e., people eligible for Medicare). That is why the Centers for Medicare and Medicaid Services (CMS) is introducing new Medicare opioid guidelines to curb the trend.

Opioid Use in Medicare Beneficiaries

Multiple studies have shown a rise in prescription opioid use in Medicare beneficiaries in the past decade.

A 2018 study in the British Medical Journal looked at opioid use data from 2007 through 2016 for 48 million people covered by either commercial insurance or Medicare Advantage plans. The researchers teased apart data for those who were eligible for Medicare based on age compared to those who qualified based on disability.

Age-eligible Medicare beneficiaries had a 12% to 15% increase in prescription opioid use over that time compared to a 26% to 39% increase for disabled Medicare beneficiaries.

Overall, the prevalence of opioid use increased by 3% for people on Medicare but showed no change for people on non-Medicare commercial plans.

A study in the Journal of Managed Care and Specialty Pharmacy in January 2019 focused on claims data for more than 15.5 million beneficiaries on traditional fee-for-service (FFS) Medicare between 2010 and 2011. The researchers used diagnostic codes from these claims to identify cases of misuse and abuse of prescription opioids. Approximately half of all Medicare beneficiaries used at least one prescription opioid during that time. Misuse and abuse were seen at a 1.3% rate and was more prominent in disabled Medicare beneficiaries, accounting for 76.2% of those cases. 

Overall, these rates were higher than previously recognized data for commercial insurance (0.65%), Medicaid (0.87%), or the Veterans Health Administration (1.1%).

The data seems to suggest that Medicare beneficiaries, whether they are on traditional Medicare or Medicare Advantage, are more likely to be prescribed opioid therapies and are at higher risk for abuse. Medicare opioid guidelines may help to decrease opioid use in at-risk individuals.

The Federal Government Targets Opioid Use

The federal government is taking steps to address the opioid epidemic by introducing Medicare opioid guidelines. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was passed in October 2018. The legislation is multi-pronged and aims to decrease opioid abuse in a number of ways.

This includes, but is not limited to, creation of new and expansion of existing programs to treat substance use disorders, increasing funding for residential treatment programs for pregnant and postpartum women, authorization of grants for states to improve their prescription drug-monitoring programs, expanding the use of telehealth services, and funding research and development of new non-addictive painkillers and non-opioid drugs and treatments. 

For Medicare beneficiaries, SUPPORT may have significant implications. The legislation allows CMS to refuse payments for opioid medications if it is determined that someone is at-risk for abuse. This involves looking at the dose of opioid medications relative to morphine (morphine equivalents), the number of medical providers prescribing an opioid drug to a given person, and the number of pharmacies used to fill those prescriptions for that person.

Looking at data in six-month intervals between 2011 and 2014, CMS noted that opioids were overutilized by 0.37% to 0.58% of the Medicare population and were associated with a mortality of 3.91% to 7.55% over that time.

Unfortunately, the method CMS uses to identify those people at risk for opioid abuse may not be very sensitive, meaning that it can miss a lot of cases.

Also, many people were flagged as being high-risk even when they never came to develop a substance abuse disorder.

Medicare Part D Policy Changes in 2019

New Medicare Part D policies have been introduced in 2019 to further address prescription opioid use. People with chronic pain syndromes will especially want to take note.

  • If you are receiving a new opioid medication for acute pain, you will be limited to a seven-day supply. If more medication is needed, a medical provider will need to seek Part D approval through a “coverage determination”.
  • If you are prescribed long-term opioid medications, you may be required to get your prescriptions from a designated medical provider(s). The goal is to improve care coordination and to decrease the risk of overprescribing.
  • A safety alert will be triggered at the pharmacy if you take an opioid medication and a benzodiazepine at the same time. Both classes of medication have addictive potential. Taken together, there is also an increased risk of overdose.
  • A safety alert will be triggered at the pharmacy if you receive a dose or quantity of opioid medication that exceeds a certain limit, depending on the drug in question.

These rules will not apply to everyone. Residents of long-term care facilities, people being treated for cancer-related pain, and beneficiaries in hospice, palliative, or end-of-life care will be exempt from these Part D policy changes.

A Word From Verywell

The federal government is taking steps to curb opioid abuse. CMS is not only refusing to pay for opioid medications in high-risk cases but they are also changing several Part D policies as they relate to prescription opioid coverage. While these Medicare opioid guidelines won’t apply to people residing in nursing homes, people receiving treatment for cancer-related pain, or people receiving end of life care, there are many people who rely on long-term opioid therapies for chronic pain.

These policy changes could make it harder for them to get the treatment they need. If this applies to you, be sure to speak with your healthcare provider to explore your best options.

I have a lot of VERY MIXED EMOTIONS about this… there are a number of  VAGUE STATEMENTS in this article… It all depends on someone who has the ability to enforce these things make a decision as to what they mean.

what does a designated medical provider(s) actually mean ? Does this mean that CMS – or some other entity – determines by some statistical number docs who a pain pt can see ?

This is something that Medicaid has done for a long time for verifiable pt who is a doc/pharmacy shopper.

This whole process maybe a pilot program for how if/when we go to a national health insurance and how they will be able to control cost – think ration care.

They already are putting in this process that they are going to use the MME calculators which I recently posted about The Myth of Morphine Equivalent Daily Dosage   that basically stated that those calculators are basically  CRAP !  But things that are incorrect or flat out bad… has never interfered with the government  following thru with its agenda.

This is just another good example of until the chronic pain community comes together and puts their dollars together and create a non-profit and hire a law firm, PR firm and lobbyist firm to be on the lookout and possible prevent such things from being implemented… various parts of the bureaucracy is going to STEAMROLL over the community.

2 Responses

  1. I’m in!

  2. I couldnt agree with you more Steve. I dont believe we will ever be “heard” until we start filing lawsuits. I been asking for a year advice an my “liability” if I started a “Go Fund Me’ page. I havent gotten an answer. If there really is 50 million CPP and they donated $1.00 a month we could hire the best law firms in the country. It seems when push comes to shove with the CPP community and we need a donation the 50 million turns into 50 . If you know of anyone that could guide me in starting a page,It will be a start and hopefully “snowball” into the $50 million a month, $1.00 can do Thank you

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