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The American Society of Hematology (ASH) has released a new policy statement in favor of safeguarding access to opioids for hematology patients with chronic, severe pain as policymakers consider restrictions on opioid prescribing.
The statement is a recognition from ASH officials of the large number of opioid overdose deaths that involve prescription medication, and an acknowledgment that hematologists need to be advocates for their patients, said Joseph Alvarnas, MD, of City of Hope, Duarte, Calif.
The scope of the opioid problem is significant and worsening. More than 200,000 people in the United States died from overdoses related to prescription opioids. And in 2016, about 46 people were dying every day from prescription opioid overdoses, according to the Centers for Disease Control and Prevention.
In October 2017, President Trump declared that the opioid crisis was a nationwide “public health emergency” and regulators with the Centers for Medicare % Medicaid Services have already put in place restrictions on opioid dosing through the Medicare Part D program.
In a rule finalized in April 2018, the CMS placed restrictions on the dosage of opioids available for chronic opioid users and limited the days’ supply for first-time opioid users. For chronic users, the CMS set a 90-morphine-milligram-equivalent (MME) per day limit that triggers pharmacist consultation with the prescriber. The agency instructed health plans to implement an “opioid care coordination edit” that would be triggered at 90 MME per day across all opioid prescriptions and would require pharmacists to contact prescribers to override for a higher dosage.
The entire exchange must be documented. The CMS instructed health plans in the Medicare Part D program to implement a “hard safety edit” that limits opioid prescription fills to no more than a 7-day supply for opioid-naive patients being treated for acute pain. The changes are set to take effect in January 2019.
But Diane E. Meier, MD, director of the Center to Advance Palliative Care in New York, said the most current data suggest the risk of addiction and substance use disorder among medically-ill patients taking opioids is less than 10%. “That means that 90% of patients with a serious medical illness can safely take opioids for the relief of pain that is causing functional disorder,” she said.
Policymakers should not conflate the use and prescription of opioids with cases of misuse and abuse, Dr. Alvarnas said. Some patients will require a higher dose of opioids depending on their age or number of pain episodes, or because of their body’s physiological response.
Some policies, such as a prior authorization, create “artificial barriers and delays in getting access to medication” for these patients, Dr. Alvarnas said. “When you create a far more arduous prior [authorization] process or limit prescriptions ... if someone has a severe blood disorder or a bone cancer, then what you’re doing is setting up a system that will fail those patients on a regular basis,” he said.
Patients may also have difficulty finding pharmacies that dispense opioid medications, or doctors who will prescribe them, because of fear of repercussions from the Drug Enforcement Administration or their state licensing boards, Dr. Meier said.
No ‘one-size-fits-all’
Because treatment is individualized, there is no “one-size-fits-all” approach to pain management for patients with hematological diseases.
“One of the concerns is that we care for populations of patients, such as those with sickle cell disease, those with blood cancers that can cause destructive bony lesions like somebody with multiple myeloma might experience, or even pain associated with the complication of a disease like hemophilia, where [patients experience] excruciating pain ... from bleeding into a joint,” Dr. Alvarnas said.
It’s not enough to offer anti-inflammatory medications to these patients – and in some cases doing so may create additional problems, experts said. Contraindications for anti-inflammatory agents tend to be more significant in hematology patients because of low platelet counts, liver disease, and kidney disease. This may prevent them from taking medications such as ibuprofen, acetaminophen, or naproxen sodium. Opioids are the “only option” for patients with these kinds of complications who have severe pain, Dr. Osunkwo said.
Pain management training
While hematologists are trained about the potential risks of common drugs such as steroids, “none of that education and training has occurred” for opioids, Dr. Meier said.
Since hematologists often aren’t trained in pain management, many are uncomfortable with managing pain in their diagnosis and leave the responsibility to a pain specialist, Dr. Osunkwo said. “But the problem is, they know more about the disease than anybody else, and you’ll be safer if [they] are doing the pain management for hematology patients because they know the risk and benefit of the different drugs in light of the diagnosis itself, compared to passing that on to somebody else to manage.”
In the recent policy statement, ASH leaders committed to creating evidence-based guidelines and education activities on pain management.
Finding balance
ASH leaders recognize the longstanding, complex nature of the opioid epidemic and want to be a part of the conversation to ensure their patients’ needs and considerations are met in future legislation, Dr. Alvarnas noted.
Dr. Meier, who is vice chair for public policy at Icahn School of Medicine at Mount Sinai, New York, said the issue of balance is paramount when considering good policymaking.
“No policy at either extreme is the right policy,” Dr. Meier said. “Good policymaking, good public health interventions attempt to achieve some balance ... in preventing harm and maximizing appropriate treatment of vulnerable, seriously ill patients. And the policies we have now don’t achieve that.”
The “Statement on Opioid Use in Patients with Hematologic Diseases and Disorders” is available on the ASH website.
Dr. Alvarnas is chair of the society’s Committee on Practice. Dr. Meier and Dr. Osunkwo reported having no relevant financial disclosures.
The American Society of Hematology (ASH) has released a new policy statement in favor of safeguarding access to opioids for hematology patients with chronic, severe pain as policymakers consider restrictions on opioid prescribing.
The statement is a recognition from ASH officials of the large number of opioid overdose deaths that involve prescription medication, and an acknowledgment that hematologists need to be advocates for their patients, said Joseph Alvarnas, MD, of City of Hope, Duarte, Calif.
The scope of the opioid problem is significant and worsening. More than 200,000 people in the United States died from overdoses related to prescription opioids. And in 2016, about 46 people were dying every day from prescription opioid overdoses, according to the Centers for Disease Control and Prevention.
In October 2017, President Trump declared that the opioid crisis was a nationwide “public health emergency” and regulators with the Centers for Medicare % Medicaid Services have already put in place restrictions on opioid dosing through the Medicare Part D program.
In a rule finalized in April 2018, the CMS placed restrictions on the dosage of opioids available for chronic opioid users and limited the days’ supply for first-time opioid users. For chronic users, the CMS set a 90-morphine-milligram-equivalent (MME) per day limit that triggers pharmacist consultation with the prescriber. The agency instructed health plans to implement an “opioid care coordination edit” that would be triggered at 90 MME per day across all opioid prescriptions and would require pharmacists to contact prescribers to override for a higher dosage.
The entire exchange must be documented. The CMS instructed health plans in the Medicare Part D program to implement a “hard safety edit” that limits opioid prescription fills to no more than a 7-day supply for opioid-naive patients being treated for acute pain. The changes are set to take effect in January 2019.
But Diane E. Meier, MD, director of the Center to Advance Palliative Care in New York, said the most current data suggest the risk of addiction and substance use disorder among medically-ill patients taking opioids is less than 10%. “That means that 90% of patients with a serious medical illness can safely take opioids for the relief of pain that is causing functional disorder,” she said.
Policymakers should not conflate the use and prescription of opioids with cases of misuse and abuse, Dr. Alvarnas said. Some patients will require a higher dose of opioids depending on their age or number of pain episodes, or because of their body’s physiological response.
Some policies, such as a prior authorization, create “artificial barriers and delays in getting access to medication” for these patients, Dr. Alvarnas said. “When you create a far more arduous prior [authorization] process or limit prescriptions ... if someone has a severe blood disorder or a bone cancer, then what you’re doing is setting up a system that will fail those patients on a regular basis,” he said.
Patients may also have difficulty finding pharmacies that dispense opioid medications, or doctors who will prescribe them, because of fear of repercussions from the Drug Enforcement Administration or their state licensing boards, Dr. Meier said.
No ‘one-size-fits-all’
Because treatment is individualized, there is no “one-size-fits-all” approach to pain management for patients with hematological diseases.
“One of the concerns is that we care for populations of patients, such as those with sickle cell disease, those with blood cancers that can cause destructive bony lesions like somebody with multiple myeloma might experience, or even pain associated with the complication of a disease like hemophilia, where [patients experience] excruciating pain ... from bleeding into a joint,” Dr. Alvarnas said.
It’s not enough to offer anti-inflammatory medications to these patients – and in some cases doing so may create additional problems, experts said. Contraindications for anti-inflammatory agents tend to be more significant in hematology patients because of low platelet counts, liver disease, and kidney disease. This may prevent them from taking medications such as ibuprofen, acetaminophen, or naproxen sodium. Opioids are the “only option” for patients with these kinds of complications who have severe pain, Dr. Osunkwo said.
Pain management training
While hematologists are trained about the potential risks of common drugs such as steroids, “none of that education and training has occurred” for opioids, Dr. Meier said.
Since hematologists often aren’t trained in pain management, many are uncomfortable with managing pain in their diagnosis and leave the responsibility to a pain specialist, Dr. Osunkwo said. “But the problem is, they know more about the disease than anybody else, and you’ll be safer if [they] are doing the pain management for hematology patients because they know the risk and benefit of the different drugs in light of the diagnosis itself, compared to passing that on to somebody else to manage.”
In the recent policy statement, ASH leaders committed to creating evidence-based guidelines and education activities on pain management.
Finding balance
ASH leaders recognize the longstanding, complex nature of the opioid epidemic and want to be a part of the conversation to ensure their patients’ needs and considerations are met in future legislation, Dr. Alvarnas noted.
Dr. Meier, who is vice chair for public policy at Icahn School of Medicine at Mount Sinai, New York, said the issue of balance is paramount when considering good policymaking.
“No policy at either extreme is the right policy,” Dr. Meier said. “Good policymaking, good public health interventions attempt to achieve some balance ... in preventing harm and maximizing appropriate treatment of vulnerable, seriously ill patients. And the policies we have now don’t achieve that.”
The “Statement on Opioid Use in Patients with Hematologic Diseases and Disorders” is available on the ASH website.
Dr. Alvarnas is chair of the society’s Committee on Practice. Dr. Meier and Dr. Osunkwo reported having no relevant financial disclosures.
The American Society of Hematology (ASH) has released a new policy statement in favor of safeguarding access to opioids for hematology patients with chronic, severe pain as policymakers consider restrictions on opioid prescribing.
The statement is a recognition from ASH officials of the large number of opioid overdose deaths that involve prescription medication, and an acknowledgment that hematologists need to be advocates for their patients, said Joseph Alvarnas, MD, of City of Hope, Duarte, Calif.
The scope of the opioid problem is significant and worsening. More than 200,000 people in the United States died from overdoses related to prescription opioids. And in 2016, about 46 people were dying every day from prescription opioid overdoses, according to the Centers for Disease Control and Prevention.
In October 2017, President Trump declared that the opioid crisis was a nationwide “public health emergency” and regulators with the Centers for Medicare % Medicaid Services have already put in place restrictions on opioid dosing through the Medicare Part D program.
In a rule finalized in April 2018, the CMS placed restrictions on the dosage of opioids available for chronic opioid users and limited the days’ supply for first-time opioid users. For chronic users, the CMS set a 90-morphine-milligram-equivalent (MME) per day limit that triggers pharmacist consultation with the prescriber. The agency instructed health plans to implement an “opioid care coordination edit” that would be triggered at 90 MME per day across all opioid prescriptions and would require pharmacists to contact prescribers to override for a higher dosage.
The entire exchange must be documented. The CMS instructed health plans in the Medicare Part D program to implement a “hard safety edit” that limits opioid prescription fills to no more than a 7-day supply for opioid-naive patients being treated for acute pain. The changes are set to take effect in January 2019.
But Diane E. Meier, MD, director of the Center to Advance Palliative Care in New York, said the most current data suggest the risk of addiction and substance use disorder among medically-ill patients taking opioids is less than 10%. “That means that 90% of patients with a serious medical illness can safely take opioids for the relief of pain that is causing functional disorder,” she said.
Policymakers should not conflate the use and prescription of opioids with cases of misuse and abuse, Dr. Alvarnas said. Some patients will require a higher dose of opioids depending on their age or number of pain episodes, or because of their body’s physiological response.
Some policies, such as a prior authorization, create “artificial barriers and delays in getting access to medication” for these patients, Dr. Alvarnas said. “When you create a far more arduous prior [authorization] process or limit prescriptions ... if someone has a severe blood disorder or a bone cancer, then what you’re doing is setting up a system that will fail those patients on a regular basis,” he said.
Patients may also have difficulty finding pharmacies that dispense opioid medications, or doctors who will prescribe them, because of fear of repercussions from the Drug Enforcement Administration or their state licensing boards, Dr. Meier said.
No ‘one-size-fits-all’
Because treatment is individualized, there is no “one-size-fits-all” approach to pain management for patients with hematological diseases.
“One of the concerns is that we care for populations of patients, such as those with sickle cell disease, those with blood cancers that can cause destructive bony lesions like somebody with multiple myeloma might experience, or even pain associated with the complication of a disease like hemophilia, where [patients experience] excruciating pain ... from bleeding into a joint,” Dr. Alvarnas said.
It’s not enough to offer anti-inflammatory medications to these patients – and in some cases doing so may create additional problems, experts said. Contraindications for anti-inflammatory agents tend to be more significant in hematology patients because of low platelet counts, liver disease, and kidney disease. This may prevent them from taking medications such as ibuprofen, acetaminophen, or naproxen sodium. Opioids are the “only option” for patients with these kinds of complications who have severe pain, Dr. Osunkwo said.
Pain management training
While hematologists are trained about the potential risks of common drugs such as steroids, “none of that education and training has occurred” for opioids, Dr. Meier said.
Since hematologists often aren’t trained in pain management, many are uncomfortable with managing pain in their diagnosis and leave the responsibility to a pain specialist, Dr. Osunkwo said. “But the problem is, they know more about the disease than anybody else, and you’ll be safer if [they] are doing the pain management for hematology patients because they know the risk and benefit of the different drugs in light of the diagnosis itself, compared to passing that on to somebody else to manage.”
In the recent policy statement, ASH leaders committed to creating evidence-based guidelines and education activities on pain management.
Finding balance
ASH leaders recognize the longstanding, complex nature of the opioid epidemic and want to be a part of the conversation to ensure their patients’ needs and considerations are met in future legislation, Dr. Alvarnas noted.
Dr. Meier, who is vice chair for public policy at Icahn School of Medicine at Mount Sinai, New York, said the issue of balance is paramount when considering good policymaking.
“No policy at either extreme is the right policy,” Dr. Meier said. “Good policymaking, good public health interventions attempt to achieve some balance ... in preventing harm and maximizing appropriate treatment of vulnerable, seriously ill patients. And the policies we have now don’t achieve that.”
The “Statement on Opioid Use in Patients with Hematologic Diseases and Disorders” is available on the ASH website.
Dr. Alvarnas is chair of the society’s Committee on Practice. Dr. Meier and Dr. Osunkwo reported having no relevant financial disclosures.