Oregon health officials have backed off of a proposal that would have limited Medicaid coverage of opioids for certain chronic pain conditions to 90 days and forced patients who have been taking opioids for longer to be tapered off those medications within a year.
Instead, the task force will consider a new approach next week offering chronic pain patients alternative treatments but leaving the decision about long-term opioid treatment or tapering largely to patients and their doctors. The proposal acknowledges that long-term opioid use may be appropriate for some.
The original proposal met with significant outcry from chronic pain patients who held protests in Salem and packed task force meetings to denounce the proposal.
“We were really listening to that feedback,” said Dr. Dana Hargunani, chief medical officer for the Oregon Health Authority. “Now, there are options for long-term opioids for certain individuals if certain conditions are covered. That’s different than before.”
Representatives of the Oregon Pain Action Group, which organized the protests, said they are reviewing the new proposal and would provide more detailed feedback at the task force’s Wednesday meeting.
“We applaud the Governor and her Senior Health Advisor, Tina Edlund, in addressing the concerns of the Oregon Pain Action Group regarding the Chronic Pain Task Force’s new proposal for the treatment of a chronic pain for Oregon Medicaid patients,” Wendy Sinclair, a co-founder of the group, wrote in an emailed statement. “We are appreciative of the Task Force’s work towards engaging with new testimony and input from national experts.”
The Oregon Health Plan has a unique structure among state Medicaid programs, relying on a prioritized list of health services, ranked by experts in order of importance to patients. State lawmakers then decide where in the prioritized list to draw the line between covered and uncovered services.
The five chronic pain conditions under consideration — fibromyalgia, chronic pain syndrome, chronic pain due to trauma, other chronic postprocedural pain and other chronic pain — fall below the line.
The proposal will add those five conditions to the prioritized list above the existing cutoff. The Oregon Health Plan would cover alternative treatments such as yoga, acupuncture or physical therapy.
Oregon Health Authority officials estimated that about 67,400 people would gain coverage to alternative pain treatments under the proposal, and that between 600 to 1,200 patients would need to have their opioid treatments re-evaluated by their providers.
The task force received extensive written comments, heard emotional pleas from chronic pain patients and collected expert testimony from doctors who treat pain or substance abuse disorders.
In response, the task force added new members with expertise in chronic pain treatment and substance use disorders. The members requested an updated review of the evidence supporting the safety and effectiveness of tapering patients. That review, conducted by researchers from Oregon Health & Science University, found there was little high-quality evidence to suggest that tapering patients off opioids improved pain, functioning or quality of life. Similarly, there was little evidence about the potential risks of weaning patients off opioids.
One study conducted using a Veterans Affairs database found that out of 509 patients tapered involuntarily, 59 expressed suicidal thoughts and 12 had attempted suicide. Only 15 the patients had contemplated suicide prior to the tapering.
Another study conducted in Washington state found few differences between patients who were tapered and a control group in terms of pain intensity, depression or the ability to undertake activities and to enjoy life. But the review said both studies had methodological flaws that limited their usefulness.
Oregon Health Authority staff interviewed representatives from the regional Coordinated Care Organizations who provide care to Oregon Health Plan members about their implementation of new back pain guidelines that also provided alternative pain management treatments but required tapering off opioids after a year. The CCOs reported that new back pain guidelines increased costs with the addition of the new services. They also reported challenges in finding yoga services for their members due to the nonmedical nature of how most yoga services are provided.
The new proposal lists a set of conditions that need to be met for long-term opioid therapy, including limits on daily dose, no concurrent prescribing of benzodiazepines and annual urine drug testing for illicit drug use.
For patients for whom a taper plan is appropriate, the new proposal recommends a complete taper, but does not require a specific time frame to achieve that. The proposal would make similar changes to the back pain guidelines that had been in place since 2016.
If approved by the Chronic Pain Task Force, the proposal would be forwarded to the Value-based Benefits Subcommittee in January. That subcommittee could pass the proposal to the Health Evidence Review Committee in March, for possible implementation at the start of 2020.
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