The Missing Piece in the CMS Opioid Misuse Strategy

By: Mario Ramirez, MD

Reading Time: 2 minutes

Date: 04/09/2017

Filed Under: Healthcare, Clinician Perspective, Opioid Epidemic

This morning, I read with great interest the Centers for Medicare and Medicaid Services (CMS) Opioid Misuse Strategy. As I’ve written about in prior blog posts, and as others have also noted in a variety of fora, our country is experiencing a profound opioid crisis across all socioeconomic classes of our society. As the U.S. Surgeon General, Dr. Vivek Murthy recently commented, physicians are partially to blame for the problem as we’ve misprescribed these medications under the pretense that they were not addictive when used to manage legitimate pain. We now know that to be untrue and CMS statistics clearly show that physician prescribing practices have accelerated the problem. The document highlights four priority areas for action including:

  • Implementing more effective person-centered and population-based strategies to reduce the risk of inappropriate use and diversion
  • Expanding naloxone use
  • Expanding diagnosis and treatment of opioid use disorders
  • Increasing the use of evidence-based practices for pain management

I wholeheartedly support these goals and believe the document lays out an actionable set of sub-recommendations that can be used to measure progress against them. In my opinion, however, this strategy is incomplete.


Unfortunately missing from the strategy—and something that has been absent from much of the recent narrative—is a focus on the realization that opioid prescription practices are a two-party interaction that includes the patient’s will often times just as much as the physician’s. There is no question that it is ultimately the physician’s responsibility to act in the patient’s best interest at all times including the denial of certain opioid prescriptions when it is dangerous or irresponsible to provide these medications. But, I firmly believe that a pillar of an effective opioid crisis management strategy must begin to engage the public on the broader issues of realistic pain management and what can realistically be achieved with the medications and evidence we currently have. For too long, the message to our patients has been that any pain or discomfort is unacceptable and that they should aggressively push to have medications added. As clinicians, we are now practicing in an environment where our patients come with requests for pain management that are influenced by print and social media advertising, conversations with others, or incomplete internet research.

If we are going to truly influence opioid abuse in our country, we must begin to act on both sides of the patient physician equation. Strategies, some of which are advocated in the CMS document, that only provide information on prescription rates or statistical outliers, run the risk of creating an adversarial patient physician relationship where one party is trying to “out-game” the other with asymmetric knowledge. Instead, we need to augment these important approaches with a strategy that engages patients as much as physicians. Tools such as AffirmHealth’s Dash software play an important role in this approach by clearly presenting the same information to patients and physicians which in turn facilitates a cooperative relationship and approach to pain management that engages both parties equally.

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