Protecting Patients from Harm: Preventing Prescription Drug Abuse in Medicare

For 50 years, Medicare has helped ensure that senior citizens and those with disabilities have access to high-quality health care in the United States. Many Medicare recipients suffer from painful chronic conditions, such as arthritis, while others have experienced falls or surgeries. Most if not all of these patients look to their health care providers for pain relief.

Physicians have long prescribed narcotic pain relievers, known as opioids, to patients with severe pain. The vast majority of these patients do not experience significant adverse effects from these drugs. However, more than 16,000 Americans die each year from opioid-related prescription drug overdoses¹, an increase of more than 300 percent since 1998. And the rate at which health care professionals prescribed these drugs quadrupled between 1999 and 2010.²

Within the Medicare population, nearly 9 million individuals—28 percent of all beneficiaries—received opioids in 2011 to treat pain not associated with cancer treatment or hospice care, and approximately 225,000 of them took potentially life-threatening doses of these pain relievers for 90 or more consecutive days.³  Twenty-eight percent of the 225,000 patients obtained their prescriptions from four or more prescribers. Eighteen percent used four or more pharmacies to obtain their drugs, and approximately 10 percent of the 225,000 visited at least four prescribers and four pharmacies to obtain their drugs.

When patients with chronic, debilitating pain seek relief from multiple prescribers and pharmacies, it is often difficult to know if they are taking too much pain medication and putting their health at risk. But Medicare can help protect beneficiaries from harm by implementing patient review and restriction, or PRR, programs—tools designed to prevent the inappropriate use of pain medication while ensuring access for patients with legitimate medical needs.

PRR programs ensure that patients deemed at risk for prescription drug abuse obtain and fill prescriptions for controlled substances only from designated providers. At the same time, these programs offer several patient protections, such as allowing patients to make suggestions on designated prescribers and pharmacies, giving individuals the opportunity to appeal enrollment in the program and excluding patients receiving hospice care and treatment for certain cancers.

Use of PRR programs have proved successful for state Medicaid plans, decreasing the number narcotic prescriptions and reducing patients’ visits to multiple providers and emergency rooms, while also generating cost savings.⁴ Now, there is growing interest from members of Congress to implement these programs in Medicare. U.S. Senators Pat Toomey (R-PA), Rob Portman (R-OH), Sherrod Brown (D-OH), and Tim Kaine (D-VA) are expected to introduce legislation that would grant Medicare the authority to use these programs; and the 21st Century Cures Act, passed by the U.S. House of Representative in early July, would do the same.

President Lyndon B. Johnson (D) signed the Medicare program into law July 30, 1965, proclaiming that “no longer will older Americans be denied the healing miracle of modern medicine.” Medicine has changed dramatically in the past 50 years, but the ideals of the Medicare program—caring for elderly, sick, and vulnerable Americans—remain the same. Congress can help stem the prescription drug abuse epidemic and protect our nation’s seniors and those with disabilities from harm by allowing Medicare to implement PRR programs.

Cynthia Reilly is director of Pew’s prescription drug abuse project.

Endnotes

1. Centers for Disease Control and Prevention, “QuickStats: Rates of Deaths From Drug Poisoning and Drug Poisoning Involving Opioid Analgesics—United States, 1999–2013,” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a10.htm?s_cid=mm6401a10_e.
2. Centers for Disease Control and Prevention, “Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008,” Morbidity and Mortality Weekly Report 60 (2011): 1–6, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm.
3. Tudor, Cynthia G., director, Medicare Drug Benefit and C and D Data Group, Centers for Medicare & Medicaid Services, “Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D,” correspondence (Sept. 6, 2012), http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf.
4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, “Patient Review & Restriction Programs: Lessons Learned From State Medicaid Programs” (2012), http://www.cdc.gov/homeandrecreationalsafety/pdf/PDO_patient_review_meeting-a.pdf.