American Society of Anesthesiologists Comes Out Against Oregon's Plan to Taper Chronic Pain Patients Off Meds

Update: The Oregon Health Authority’s pain and evidence committees were slated to vote on Mar. 14 about finalizing mandated opioid cut-offs to zero for Medicaid patients with 170 different pain conditions. The Oregon panel tabled the vote.

The American Society of Anesthesiologists (ASA) has come out against a proposal to taper certain chronic pain patients on the Oregon Health Plan off opioids. In a letter to the Oregon Health Authority published earlier this month, Linda Mason, president of the ASA, wrote that the organization is concerned the policy “goes too far” for some chronic pain patients.

Back in June, Oregon’s pain advisory committee, called the Chronic Pain Task Force, revealed its plan to limit coverage of opioid prescriptions for those signed up for the state’s Medicaid health plan. People using opioids for five chronic pain conditions — fibromyalgia, centralized pain syndrome, chronic pain due to trauma, other chronic postprocedural pain, and “other chronic pain” —  would lose coverage for opioids after 90 days and would have to completely taper off opioids within one year. The plan also added coverage of non-opioid treatments, such as massage, physical therapy, acupuncture and yoga, for these five conditions.

Chronic pain patients were outraged by the proposal and attended protests and task force meetings to explain the devastating impact losing opioids could have on their pain levels and quality of life.

As a result, in early December the task force revised their recommendation to leave the decision of long-term opioid use and tapering timeframe to patients and their doctors while recommending patients be tapered off opioids if their condition is not being treated effectively. But the task force’s new plan still excludes coverage for opioids used to treat fibromyalgia and centralized pain syndrome, since the task force concluded opioids are not beneficial for those conditions.

Echoing others who have criticized the proposal, Mason explained that in many cases, long-term opioid use results in relief from pain, restored function and the ability to work. Meanwhile, a forced taper can lead to serious mental health concerns and even suicide, as well as patients turning to other alternatives such as illegally obtained drugs. Safe alternatives to opioids like physical therapy and injections are not always available, either.

“The [Oregon] Chronic Pain Task Force has demonstrated that there is little evidence or studies available on opioid tapering,” Mason wrote. “ASA agrees and therefore, questions why Oregon would choose this route.”

The proposal asks for annual urine tests, no simultaneous prescribing of benzodiazepines such as Xanax, and limiting prescriptions to 50 morphine milligram equivalents (MME) or up to 90 MME in some cases. Patients already taking doses higher than these limits would have to begin to taper down to the limit (or taper completely off if they have fibromyalgia or centralized pain syndrome), though the timeline would be up to the patient and their doctor.

While policies like Oregon’s are meant to curb addiction and death due to opioids, the latest CDC data found that deaths due to prescription opioids have stayed roughly the same in recent years while deaths due to illicit fentanyl, an extremely potent opioid found in trace amounts in other illegal drugs, have skyrocketed. Most people using opioids for chronic pain do not become addicted.

In her letter, Mason acknowledged opioid have the potential for misuse but urged the task force not to interfere with the ability of a doctor to use their own training to prescribe an individualized treatment plan which may include opioids.

“The Society also encourages the Task Force to continue exploring expansion of coverage for opioid alternative pain management treatments. Yet, these methods cannot and should not replace access to opioids,” she wrote.

In response to the new plan’s softening of the tapering requirement, a statement on the ASA website said the organization is encouraged, but still “cautions the state to be explicit in their final policy to ensure the implications to patients do not have unintended consequences.”

The task force’s proposal will be reviewed in January and if approved, would go to the Health Evidence Review Commission for final approval. The final plan would go into effect in January 2020.