September 10, 2018

Governor Kate Brown and Oregon Health Authority Director Patrick Allen:

We are writing to you as Oregonians who are living with chronic pain conditions. We want to share our concern about the Prioritized list changes proposed by the Health Evidence Review Commission (HERC) to eliminate coverage of long-term opioid therapy for most OHP/Medicaid members.

The proposed changes, referenced in Guideline Note 60, are based on the recommendations of the Oregon Chronic Pain Task Force (Task Force). The proposed changes would limit new opioid prescriptions to a maximum of 90 days and force an involuntary taper for all persons presently receiving opioids for chronic pain.

Patients would instead be offered “active therapy” (physical therapy, acupuncture, massage therapy, cognitive behavioral therapy) and/or non-opioid medication.

We share your concerns about substance abuse and we agree that services need to be expanded to help those struggling with addiction. However treating substance abuse is a sperate issue from this proposal which impacts only people living with chronic pain.

• Patients with chronic pain are not addicts.

We demand fair and appropriate treatment for our medical conditions without the stigma, shaming and shunning that chronic pain patients continues to endure. Dr. Daniel Carr addresses the challenges chronic pain patients face in the article, Patients with Pain Need Less Stigma, Not More [1], published in the journal Pain Medicine:

“Stigma—shaming and shunning—continues to befall patients with chronic pain, as do inequities in access to care. Tragically, people with the fewest resources to resist pain’s debilitating effects—minorities, the very young or very old, those with HIV, cancer, or substance abuse, the poor or homeless—are also marginalized by society. These “outsiders” have the least access to appropriate pain assessment and treatment. Even prosperous individuals often find their need for pain prevention or control is not addressed. Why is appropriate pain treatment so hard to deliver?”

We demand to be treated with respect and dignity; by health care providers, insurers and policy makers. We believe that this proposed policy will further stigmatize people living with chronic pain conditions as “addicts” decreasing access to medical treatment.

• We oppose the 90 day limit of opioid prescription medication for chronic pain patients.

The proposal fails to recognize the efficacy of continued opioid medication therapy for patients who do not achieve relief of painful symptoms using non-opioid therapies.
Treatment decisions should be made between providers and patients, not by state commission. Medicine should be practiced based on provider experience, clinical evidence, patient outcomes, and by weighing the benefits/risk of all available options.

• The HERC opioid prescribing proposal would be the most restrictive in the nation.

If adopted, the Prioritized List changes would make Oregon the most restrictive state in the nation[2] for Medicaid patients prescribed opioid medications. This would restrict patient and provider choice in therapy options and force patients who are currently well managed on opioid to “taper” or discontinue therapy. If this is approved it would further damage the doctor patient relationship for non-opioid medications.

• The HERC proposal is not based on current CDC Guidelines.

The current CDC Guidelines for Prescribing Opioids for Chronic Pain[3] advises. “Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. The CDC suggests discussing the benefits and risks before beginning opioid therapy, monitoring for dangerous potential drug interactions through prescription drug monitoring programs and clinical observations at reassessment in determining efficacy of continued therapy.

• HERC wants to “safely taper” patients off opioid medications, despite medical evidence that this works.

The study cited by HERC Interventions for the reduction for prescribed opioid use in chronic non-cancer pain,states “There is no evidence for the efficacy or safety of methods for reducing prescribed opioid use in chronic pain. [4].” The results of the studies referenced by the Task Force are arbitrary and inconclusive. In fact, CDC researcher Tamara Haegerich[5]clearly says that the guidelines specifically does not provide “support for involuntary or precipitous tapering. Such practice could be associated with withdrawal symptoms [and] damage to the clinician-patient relationship”. Both the current CDC and

• HERC plans to provide patients “active therapy” instead of opioid medications.

Instead of opioid medications which are effective in managing pain, patients will instead be offered “active therapy”[6] (physical therapy, acupuncture, massage therapy, cognitive behavioral therapy) and/or non-opioid medications. These types of therapies can be beneficial for some people, but they do not work for all chronic pain patients.

The effectiveness of these therapies is even questioned by the HERC Medical Director, Ariel Smits, MD. Dr. Smits stated that the evidence is “inadequate to support Tai Chi, but slightly strongerto support mindfulness therapy.[7]” Patients would be required to achieve a 15% (or better) improvement as a condition of continuing “active therapy” (physical therapy, acupuncture, massage therapy, cognitive behavioral therapy).

• What happens to the patients that don’t achieve improvement through “active therapy”?

Are their safeguards and the provisions for patients who don’t respond to alternative therapies? Will OHP consider restarting patients on opioid therapies that have previously controlled symptoms? There is great momentum to take patients off medications currently working, but no plan for what to do with those who do not respond to “active therapy”.

• OHP members have difficulties accessing “active therapy” today.

Jessica R., an OHP member testified to difficulties that she is having now in having her physical therapy sessions approved because of the limits placed on the number of visits by OHP and her Medicaid coordinated care organization (CCO) [8].

Sheila M, an acupuncturist currently working at a federally-qualified health center, treating chronic pain patients. She testified about problems with prior authorizations from CCO’s saying that they are a “barrier to patients accessing this type of care” [9].
She said that CCO acupuncture is not currently a covered therapy for many chronic pain conditions because it is not an “evidence-based” therapy. Sheila also noted that in her experience the proposed 30-visit limit would not meet the needs of chronic pain patients.

• HERC wants to limit “active therapy” visits because of cost.

Providers are concerned that patients will not have enough time in active therapy sessions to properly manage their pain, especially in response to HERC’s focus on cost effectiveness.

HERC wants “active therapy” sessions to be one time resource. They prefer patients would “successfully complete” an “active therapy” course and continue on their own using acceptance and commitment therapy, stating that “this is more cost effective than simply requiring them to continue therapy without end. [10]” Some therapies, like massage and acupuncture can only be done with practitioner to provide the treatment, how would this be an effective alternative when the limit of available sessions is reached?

People living with intractable painful medical conditions need continued access to treatments that work.

The choice between opioid/nonopioid treatment or an active therapy treatment should be made by patients and their providers. Current respected clinical publications offer recommendations on the use of opioid medications in chronic pain patients (both short and long term).

These studies offer similar guidelines to mitigate harm and reduce the risk of misuse and potentially dangerous drug interactions. In addition, Oregon already has safeguards, including appropriate patient and provider education, continued clinical assessment of treatment goals and monitoring of the Prescription Drug Monitoring Database (PDMP) to avoid potentially harmful drug interactions.

We ask that HERC halt their current proposal and allow qualified doctors to render individualized medical care as in the best interest of their patients according to their specific needs. Allowing alternative treatments is a great option to help reduce or eliminate opioid use in some patients, but it is not a substitution for many. That decision needs to be individualized between the doctor and patient. We want to ensure that these medications are available for the patients who need them.

Respectfully,

Reference Notes

[1]Carr, Daneil B, MD DABPM, FFPMANZCA (HON) Patients with Pain Need Less Stigma, Not More Pain Medicine, Volume 17, Issue 8, 1 August 2016, Pages 1391–1393, https://doi.org/10.1093/pm/pnw158 Accessed: September 2018

[2]Hawryluk, Markian, Oregon Health Plan consider stricter opioid limits. The Bulletin,July 25, 2018, Accessed: August 2018

[3]Checklist for prescribing opioids for chronic pain. US Department of Health and Human Services, Centers for Disease Control and Prevention, March 2016 https://www.cdc.gov/drugoverdose/pdf/PDO_Checklist-a.pdf, Accessed: August 2018

[4]Eccleston C, Fisher E, Thomas, KH, Hearn L, Derry S, Knaggs R, Moore, RA. Interventions for the reduction for prescribed opioid use in chronic non-cancer pain.Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.:CD010323Included in HERC Chronic Pain Task Force meeting materials, June 7, 2018

[5] Dowell, Deborah, MD, MPH & Haegerich, Tamara, PhD, “Changing the Conversation About Opioid Tapering,” Annals of Internal Medicine 167 (3) August 2017 http://annals.org/aim/article-abstract/2643843/changing-conversation-about-opioid-tapering Accessed September 2018

[6]Minutes, Chronic Pain Task Force,Apri 30, 2018 , https://www.oregon.gov/oha/HPA/CSI-HERC/Pages/Meetings-Public.aspxAccessed: August 2018

[7]Minutes, Chronic Pain Task Force,June 7, 2018 https://www.oregon.gov/oha/HPA/CSI-HERC/MeetingDocuments/CPTF%20Minutes%206-7-2018.pdf

Minutes, Chronic Pain Task Force, June 7, 2018, https://www.oregon.gov/oha/HPA/CSI-HERC/Pages/Meetings-Public.aspxAccessed: August 2018

[8]Minutes,Chronic Pain Task Force,April 30, 2018 Page 3 Public Comment, https://www.oregon.gov/oha/HPA/CSI-HERC/Pages/Meetings-Public.aspxAccessed: August 2018

[9]Minutes, Chronic Pain Task Force, June 7, 2018, Page 3, Public Testimony https://www.oregon.gov/oha/HPA/CSI-HERC/Pages/Meetings-Public.aspxAccessed: August 2018

[10]Minutes,Chronic Pain Task Force,April 30, 2018 Page 3 Discussion https://www.oregon.gov/oha/HPA/CSI-HERC/Pages/Meetings-Public.aspxAccessed: August 2018