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ASHINGTON — In the final hours of public input on a controversial new rule limiting opioid prescriptions, a last-minute coalition emerged on Monday to oppose it.

The Centers for Medicare and Medicaid Services rule would restrict opioid doses to Medicare patients to the equivalent of 90 milligrams of morphine per day.

But a vocal group of doctors, pain patients, and public health experts — including three who contributed to the Centers for Disease Control and Prevention’s own prescribing guidelines — emerged near the Monday deadline to voice their opposition via comment, letter, and social media.

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Hundreds of comments had been submitted to the CMS website on the rule as of Monday afternoon — the vast majority in opposition.

Dozens of other academics, doctors, and editors of pain journals have signed on to a letter claiming the proposed rule constitutes overreach by CMS into medical treatment and would carry serious consequences for the 1.6 million Medicare beneficiaries who reached that threshold for at least one day in 2016.

The critics say the regulation is heavy-handed and measures health outcomes only in prescription levels. The 90-milligram morphine daily equivalent is roughly equal to four mid-range doses in a typical prescription of immediate-release oxycodone.

“There are a lot of Medicare providers that already do very aggressive dose control now,” said Dr. Stefan Kertesz, a professor at the University of Alabama, Birmingham, who focuses on addiction and works with a variety of chronic pain patients. “We know what real opioid safety looks like. This is not that.”

Instead, their letter says, the approach is a one-size-fits-all response to external pressure on CMS, and one that takes decision-making power away from doctors.

Government pressure to act

This proposal echoes a similar one last year in which CMS proposed to restrict opioid doses to 120 morphine milligram equivalents per day. This year’s proposal, however, goes even further, by reducing the threshold and allowing pharmacists to deny prescriptions that exceed it. The rule would create a potentially time-consuming exemption process that would require the consent of pharmacies, payers, and doctors.

The rule, set to be finalized April 2, is the first daily opioid dose limit proposal issued under the leadership of new CMS Administrator Seema Verma.

Verma, who served as Indiana’s top health official when Vice President Mike Pence was governor there, has cited the opioid crisis as a priority, and she has been a mainstay at administration events on the topic — including the White House’s “opioids summit” held last week.

But Verma’s agency is under pressure to act from multiple government oversight bodies, which have placed much of the responsibility for high opioid prescription levels on the agency.

The Office of Inspector General in July highlighted that 1 in 3 Medicare Part D beneficiaries received opioids, for which Medicare paid $4.1 billion — a statistic Attorney General Jeff Sessions cited last week in announcing the Justice Department’s involvement in a slate of lawsuits against opioid manufacturers.

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The Government Accountability Office doubled down on the the inspector general’s conclusion in January, issuing a report titled “Medicare Should Expand Oversight Efforts to Reduce the Risk of Harm.”

CMS’ new plan does neither, its opponents argue. Among the problems they see with opioid prescribing thresholds are the potential for decreased quality of life, pursuit of illicit drugs to replace opioids, and the potential for increased suicidal ideation among patients whose opioid doses are reduced or discontinued.

“The plan avows no metric for success other than reducing certain measures of prescribing,” the letter reads. “Neither patient access to care nor patient health outcomes are mentioned.”

Instead, Kertesz said in an interview with STAT, CMS should pursue a system that considers risk factors, and develops plans of care for patients being prescribed opioids.

“This is just an elaborate, bureaucratic show of force which CMS is under pressure to produce,” he said.

While the letter’s authors acknowledged the role of opioid overprescription in creating the current crisis, their resistance to the CMS proposal comes at a time of broader concerns that the federal government’s desire to forcefully address the epidemic could come at the expense of patients. A sweeping addiction bill introduced in the Senate last week goes further than any state legislature and even the CDC guidelines in limiting first-time opioid prescriptions to three days.

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  • My rheumatologist told me in March he will no longer prescribe opiates as he does not want to end up in jail. The DEA has thrown chronic pain patients under the bus and no one cares. I just do not know what to do. I feel the pressure on my heart, as I have heart problems, and have constant headaches worrying about dealing with my pain now. Maybe I will have to go to a doctor in Mexico and get the medications I need to live with a modicum of normalcy. This is disgraceful.

  • Ah….Mary….I get where you are coming from from but that is NOT where I was going with my comment. I to live with chronic pain….have been for 10 years. Yes…..I have thought of ending my life when I can’t sleep for days and the pain is really bad before all this limit won medsq and now taking ALL MEDS AWAY. I was just making a suggestion for him to reach out to SOMEONE TO HELP HIM. So….ease up on the comment please.

    • Robin;,,,this whole holocaust of the chronically medically ill is sooo in-humane,,,,,JMO,,,,,Death truly is thee only option for some in my humble opinion,,for as a fellow cpp,,,u know,,,,our physical pain will never stop,,,unless we are given the proper amount of medicines,,,w/out that,,,we are literally dead anyways,,My point is,,,just like our physical pain,,,as FREE ADULTS in this country,,,no-one has the right to decide how much we are to forcible endure physical pain,and for how long,,Soo unless u know of a doctor ,a real MEDICAL doctor,,,that WILL prescribe this adult male his medicines,,,in my humble opinion,,,as he is an adult,,,his body,,,his choice,,,but the facts or consequences of his decision I listed,,For our government will never ever admit they have tortured,and torture many of us to death,,,Death towards a group of people,,is genocide,,,again a crime our government will never admit to,,thus why our death are cover’d up,,and not HONORED IN TRUTH!!!jmo,,,,maryw

  • Twelve yrs. of pain meds here after a large crate fell on me from a high shelf, while shopping.

    The DOCTORS prescribed every pill I’ve had since 2005!
    The PHARMACEUTICAL COMPANIES “suggested” what the DOCTORS write me, as they were handing down checks and vacations to these DOCTORS that “helped me.”

    My pain is noted as CHRONIC on my medical charts.

    This month I will not get “stepped down” as would be human, but CUT OFF!

    I predict a civil war coming. Not from the chronic pain patients, we will be too sick. But from those who love us, whose lives are about to change too.

    I’m sure there are a ton of fat cats not getting their checks from the ole’ Pharmacuticals anymore. Maybe they will understand “some” sort of pain now.

    • It has been against the law for over 40 years for any doctor is to accept a gift from any medical sales, insurance companies, pharmaceutical companies or any other type of company that would be a conflict of interest. The only thing a physician can accept is a meal that is at the worth of a bagel or a coffee. They can also accept hens if they are worth under a dollar. So what you are saying is not true you are just angry and blaming your doctor. Remember it was your doctor who tried to treat your pain. You seem to have been happy with it now you want to blame them for your addiction. You could have declined the medication at any time. Chronic pain patients know all too well what type of medication they are taking they make a point of educating themselves. You knew that an opiate was a narcotic pain medication and you had to have a special script to get this narcotic medication. All narcotics are addicting. Some patients may become addicted if they are using them everyday for months, but they make that choice rather than living in pain. You cannot blame your doctor because there are no other medications which work on you other than narcotics. If you didn’t want a narcotic and you wanted to try something else all you had to tell your doctor was exactly that. I am suspecting that nothing else worked on you other than a narcotic. It is not your doctor’s fault that you had a crate fall on you. Your doctor was only trying to help you have a better quality of life after you were injured. I cannot believe you speak so nastily about your physicians who cared about you all these years. You are exactly the type of patient which a doctor fears and ends up making the decision not to write pain meds for any patient because they are afraid you will sue them if you get them and become addicted or you will sue them because you can’t get them for your pain. There is no satisfying you you want to blame everyone else for your problems including the people who are standing there wanting to help you. You need to take a long look in the mirror and decide what kind of person you really want to be for the rest of your days on this Earth. Do you want to be kind and understanding even when things do not go your way and not lash out and blame others who have done nothing but try to help you. Or do you want to be that constant complainer who is out to hurt people who have done nothing but help you. No they cannot give it to you for free everyone has to make a living your doctor’s have families and children they need to to raise also you are not the only one that has a life to live. You are forgetting that every doctor must spend a minimum of 13 years without any income and going into serious debt just to be able to give you that prescription… And you want them to continue working for free and not be able to pay their debts back nor make up for all of the Lost income while they were out of the workforce for 13 to 20 years years or more studying just so they could take care of people like you. You probably want all your surgeries for free too. I’m guessing you are one of those people if someone were handing out free $100 bills you would complain and ask them and tell everybody what a jerk they were because if they didn’t give you $200. Normally your doctor would wean you down so you would not experience Andy uncomfortable withdrawals but if you said anything to them like you have said on this message board and accused him of making all of this money off of you and how you got nothing in return and we’re dissatisfied with everything I can kind of see why they just didn’t care anymore about someone who is so unappreciative. It’s attitudes like yours which give a bad name to the rest of chronic pain patients. Maybe you will feel better when you think of all the money that doctor is not making off of you now while you are sitting at home in pain day after day and your quality of life goes down because your pain has zapped your energy… because chronic pain is truly exhausting and those who suffer with it spend most of their lives in bed if they do not have any pain medication. But it sounds like you will be happy thinking of all the money you have saved and how miserable your doctor will be without your money once a month. Hey maybe all you needed to get rid of your chronic pain is to channel that hatred you have for the pharmaceutical company who invented the narcotic which got rid of your pain, and the doctor who prescribed the narcotic which got rid of your pain. All you need is a Tylenol or an Advil, and they’re not addicting, you don’t need your greedy doctor to prescribe it to you, and that greedy pharmaceutical company has made it so cheap it’s nearly pennies per pill.

    • Ms.Kitty;;;;its called ,”informed consent,” as adults in any country,,,,however our legal system is NOT adhering to the law of ,”informed consent,” why,,,i have no idea,,,,more money in not honoring It,I guess,,,,At anytime,,all those so-called ,”addicts,” could of said NO,,, as a responsible adult,,,sorry,,a pill does not jump up all by itself,,and jump in someone mouth all by itself,,,the person in the mirror,,chooses to swallow it,,,not the pills fault,,not the doctors fault,,or pharma,,,pharma was doing what is called in economics,,supply and demand,,,jmo,,u got these politicians’ ADULT ,”children,;; who go and steal mommy and daddy’s medicines,,and since the parents are tooo busy w/there careers,,these parents gotta blame someone besides themselves or the sons/daughters,soo they blame everyone else,,for their ADULTS offsprings poor decisions,,,,,thats where the true blame is,,,jmo,,and instead of truthfully seeing these parents opinions as bias opinion,,,the government is using these o.d. of ADULTS,,AS FACT and making abusing laws over bias opinion,,and hell the ,”addiction industry,” is a boom town right now,,and they planned it that way,,,many many shrinks are getten rich off of this FALSE EPEDIMIC,FALSE DATA,,,, on our dime,,maryw

    • Please don’t do anything bad…..please talk to your wife. Please call your doctor…..pastor….or friends and talk to them. From what I got from your email….you are looking to end it. Please CALL A HELP LINE.

    • To Robin:Hey heres an idea,,,GIVE US OUR MEDICINE BACK,,,SO WE ARE NOT FORCED TO USE DEATH TO STOP OUR NOW FORCED PHYSICAL PAIN FROM MEDICAL CONDITIONS!!,,,,,,Do u live in his body 24/7???can u physically feel the physical pain of another???NO,, it is literally impossible,,Hell our government won’t even honor our deaths in TRUTH,, just cya their own ass’s…That be true,,Mr.Erhling,,,should u be FORCED to use death to stop your now FORCED physical pain,,,u know,,,your death will be add’d w/the addicts,,right??NOT THE TRUTH OF COURSE!!!!but,,,it will cover some politicians ass….something to think about,,,anddddd,,,Life insurance pays out nothing for suicides,,soo if u have a wife,,,she will get nothing,,,just stating fact here,..Your death will be recorded as a suicide,,again NOT TRUTH,,, but our government wants no evidence of the genocide they have done!!!

      People should of just stayed out of our PRIVATE medical decision,,for it is a fact,,that no-one can physically feel the physical pain of another,,thus,,as a humane civilization,,our goal should of STAYED,to simply lessen the physical pain as effectively as possible,,,,not,,to be judge jury and yes executioners for the medically ill in now,forced physical pain,via denial of access to effective medicines to effectively lessen physical pain!!!maryw

  • I just hope all these hypocritical doctors, politicians and any one else who refuses an elderly person or a chronically ill person relief from their pain by prescribing anti-convulsion drugs and reducing opioids that work and are taken correctly by the patient should have to live the last 20 years of their lives in the most rat-infested, Nurse Cratchet hole of a nursing home and get the hell beat out of them for the horror they are responsible for perpetrating on the American People.

    • Your doctor is not the one who made these new rules. This will devastate his practice as all his patients I’m sure are pain management patients. Your doctor chose to help you because he/she was genuinely concerned about you. The state boards and the DEA offices are now sending doctors to prison when one of their patient dies of an overdose. They are holding them liable. So if you decide to commit suicide via your pain meds you will be sending your doctor to prison and they will not be able to write any more pain meds for all the other patients. So all you would be suiciders out there, you are the problem. If it wasn’t for all the deaths from people taking their prescriptions in excess not understanding that more is not better, it does not get rid of more pain it just causes you to fall asleep and stop breathing. If your pain is extremely severe pain medication can not get rid of all of it. Some people actually have to be put into a medically-induced coma to give them relief from their pain. But this is done in the hospital, and you are intubated and a machine breaths for you. When patients take more of their medication than prescribed they are heading towards that medically induced coma except there is no one there to intubate them and to breathe for them. That is the reason why all of this has come about and why all patients and doctors are now going to suffer. It is because of these deaths and doctors being directly held responsible and being sent to prison for more than 20 years, instead putting the blame on the person willfully ingesting too much of their medication, more than what was prescribed, why their families are mourning their loss and seek to blame the pharmaceutical companies and the doctor who prescribe the medication. This is why doctors do not want to prescribe pain medication anymore, they don’t want to go to prison because you or your loved one has decided to commit suicide by taking too much of their medication, or they just like taking too much of their medication. I realize I am being a little harsh but you are the problem and you don’t even see it. It is your comment about going to commit suicide that will cause your family members to blame everyone else for your actions. It’s like making everyone go to prison for the rest of their lives who works at Smith & Wesson for making the gun that you decided to kill yourself with… it’s really not your doctor’s note for the pharmaceutical companies fault that you came to them for help with your pain. You ask for their product and their service because nothing else worked and then you theoretically intentionally took more than prescribed, and now your family misses you and wants someone to blame. Opiate deaths finally reached an epidemic and the government had to act. Now they will try to limit you to a dose you can’t kill yourself with, it might even get to where you have to pick your meds up every 5 days and if you save them up and take them all at once then your family really does have no one else to blame but you. Unfortunately all other pain management patients will have to bear the burden of more restrictions. They will make you sign contracts, and they will make you sign that you were told at every visit about the addicting qualities of this medication and if you mix them with other drugs you could die. You now will have to sign this before you will get your medications. When I say you, I don’t mean you in particular I am meaning all chronic pain patients who are at their doctor’s office wanting a narcotic prescription medication. The paperwork will be increased so that your families can no longer blame the Physicians or the pharmaceutical companies for your actions of taking too much medication whether intentionally trying to commit suicide or intentionally taking more of your medication than prescribed. That is why all this is going on and people will be limited on how much medication they can have, they will be assessed at their cost via a urine exam to make sure they are not taking any other drugs, they will have to go to psychiatric appointments to make sure they are stable mentally, etc etc… All of this is solely due to deaths that have occurred do to people taking too much of their medication. They will also evaluate you psychologically to see if you are blaming your physician or the pharmaceutical company and if you are you won’t be getting any more prescriptions because you are mentally not stable enough do you have any more of this medication if you are blaming the very people who you came to for help. No one has made you choose a narcotic for your pain relief. You have other choices, they may not work but it is your choice to take them and not to take a narcotic. If you decide a narcotic is the only thing that relieves your pain then it is your choice to continue to take it. The doctor is not forcing you to take this medication and neither is the pharmaceutical company. And neither one of these entities cause you to be injured where you need pain relief. I guarantee you if they get an inkling that you are blaming them for helping you with your pain with this narcotic option, they will stop prescribing it to you, because you are a liability at that point not only to them but to other chronic pain patients.

  • I’m. So mad. I’ve been on pain meds for years and they want to take the meds away. They cannot seen to get those that are getting their drugs from. The streets so their turning their attn to us. Then ones that need meds. Why? It’s so they can say look what we did. Has anyone thought about what the suicide rate will be when. Patients are in such pain they would rather kill themselves than spend another day in pain. Has anyone addressed that? I bet not. Welcome to dictatorship! In this day and age now why would a person want to become a doctor? What’s wrong with you people? Your screwing this up just like health care. Remember?
    Word if advice. Stat the hell out of my life, because what you are doing is taking my life away!!!!!

  • It’s been a long night. I have RSD in my spine, two limbs, and my bowels don’t work properly because of the amount of nerve pain going on in my back due to the RSD. I had surgery in the spine and ended up with RSD at the sight of surgery after. I have been in pain management, same doctor, same pharmacy for more than 6 years. Now, my knees are shot and giving my grotesque amounts of pain. I cannot walk and am suffering. I saw my pain mgt. doc yesterday and he has me on a cocktail of 7 meds, most don’t do a thing, but the Oxy and the Gabapentin have their place. I told him I can’t get up out of a chair now, down steps, etc, and his response is to try to add other {cousin meds} to Gabapentin. That’s the new way of medicine, and it does NOT control this pain, and so I am suffering in agony. When I say suffering, I am not sleeping because of the pain, my days are awful because my life has been taken from me….I can barely walk because of so much pain…..
    While my body is addicted to the 40mg oxycodone I take a day, I am not abusing it and haven’t for the now 5 years I’ve been on it. With these extra issues and my pain levels gone up so much more, my doctor is scared (obviously) to treat me. So I suffer, my work (in home office) suffers, my husband suffers, we are all suffering, and you all think you are doing a good thing by pronouncing a war on drugs.
    For those of us with severe nerve pain, many are opting suicide and/or suffering through a life of dreading each moment of each day. My other docs think I am depressed (but my cocktail of meds has 2 antidepressants, so no more please and thank you, because the pain and depression are SITUATIONAL….who wouldnt be depressed???)>

    Anyway, I am suffering beyond what I can stand and looking at the doctors, the hippocratic oath, the AMA and all of these entities who have brought this on me and all I can say is …..BRAVO……another American war on something…..

    If you want to kill me off, stop the cocktail of all these meds and just freaking overdose me yourselves….and stop giving N. Korea speeches about their crimes against humanity you hypocrites.

    Sorry, I am tired, my body is screaming and I can’t get any relief…you might say I have an edge.

  • I have been in pain management for years. I have suffered threw many surgeries at this point no more can be done without high risk of being paralyzed. I also am a survivor of cerririous of the liver. This one size fits all is not the way to go. I spent the most of 2014-2017 hospitalized. I don’t think the hundreds of doctors and interns did all this for me to live the rest of what is left in my life in pain and agony

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