The recent passing of Prince, possibly from alleged use of opioid medication, is one of the many tragic news stories we read every day regarding opioid use. For the past few years, many Americans have voiced concern over the nation’s opioid public health crisis. In recent months, media coverage of opioid use, abuse, and addiction seems to have intensified, as have efforts to stem the use and abuse of these medications. While illegal drugs, such as heroin, are part of the problem, the overuse of legal, prescription drugs are also a large component of the epidemic.

In March of this year, the Centers for Disease Control and Prevention (“CDC”), issued its much-anticipated guidelines for health care providers who prescribe opioid medications. The Guidelines take the form of 12 recommendations, divided into the following three categories: (1) determining when to initiate or continue opioids for chronic pain; (2) opioid selection, dosage, duration, follow-up, and discontinuation; (3) assessing risk and addressing harms of opioid use. Each recommendation is followed by notes and scientific information regarding implementation. As an example, Recommendation 1 states: “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.” The discussion following this recommendation indicates, among other things, that “Experts agreed that opioids should not be considered first-line or routine therapy for chronic pain . . . outside of active cancer, palliative, and end-of-life care” and that opioid use “is more likely to be effective if integrated with nonpharmacologic therapy.”

These Guidelines are only voluntary, not mandatory. However, health care insurers may use the Guidelines to control the prescribing activity of providers, effectively making the rules mandatory for many providers. Indeed, at least one insurer has already imposed restrictions on opioid prescriptions by its providers. Blue Cross Blue Shield recently reported success with its Prescription Pain Medication Safety Program, a program which pre-dated the CDC Guidelines. Under this program, providers cannot issue more than a 15-day supply of painkillers at one time, and cannot prescribe more than 30 days’ worth of opioid drugs over a two-month period. Providers must also obtain prior approval from the insurer to prescribe certain medications, such as OxyContin, except in certain situations.

In light of the success of the Blue Cross program, other insurers may follow suit. If so, the insurers may vary in their restrictions, but it seems likely that the CDC Guidelines will be a starting point for any such programs. An insurer may develop its own specific requirements consistent with the Guidelines, or may refuse payment for prescriptions or services where it believes the CDC protocols are not followed. Assuming the CDC Guidelines are now considered “best practices” in the industry and by insurers, health care providers may find the Guidelines are not so voluntary after all.

Further Reading:

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016, March 18, 2016, available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

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The Affordable Care Act: Mandated Benefits Compliance Standards