New Opioid Limits in Medicaid: Protecting Access for Cancer Patients & Survivors
In the fall of 2018 the U.S. House and Senate passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act) – comprehensive legislation to address the opioid epidemic. As part of this law, Medicaid programs are required to implement limits on coverage of opioids in certain cases. The American Cancer Society Cancer Action Network (ACS CAN) strongly encourages Medicaid policymakers implementing these limits to ensure that cancer patients and survivors still have access to the pain and symptom management they need.
Cancer and Ongoing Treatment for Pain
Pain is one of the most feared symptoms for cancer patients and survivors - nearly 60 percent of patients in active treatment and 30 percent of patients who have completed treatment experience pain. Pain can be caused by the cancer itself, for instance when tumors interfere with normal body function. Pain can also be caused by cancer treatments and can persist for a long time after treatments have ended. For example, research has found that about one-quarter of women who have had breast cancer surgery have significant and persistent breast pain six months after the procedure.
In September 2019, ACS CAN – through our Survivor Views project – surveyed cancer patients and survivors about pain and palliative care issues. We found that:
- 60 percent of patients surveyed who reported having pain had this pain after their active cancer treatment ended. For patients who experienced pain after active cancer treatment, 40 percent of patients experienced this pain for more than one year after treatment.
- 41 percent of cancer patients and survivors surveyed - who have filled an opioid prescription in the last 12 months - say they have encountered at least one barrier to accessing that treatment. Our data also show that individuals who had challenges accessing opioids are 20 percent more likely to say they had pain after active treatment ended.
New Required Medicaid Limits on Opioids
The SUPPORT Act requires Medicaid programs (including managed care plans) to have a drug review and utilization (DUR) program that implements “safety edits” – checks at the pharmacy – for opioid prescriptions that are refilled, over a certain dosage amount, or that are prescribed concurrently with certain other drugs.
Medicaid programs are required to:
- Implement a safety edit on “subsequent fills” (i.e. refills) of opioid prescriptions, and a system that identifies patients who receive duplicate fills, early fills, and fills in excess of quantity limitations – to be determined by the state.
- Implement a safety edit when a patient fills a prescription that is over the maximum daily morphine equivalent (MME) dosage limit determined by the state. This limit only applies to treatment for chronic pain.
- Implement a system that identifies patients who are prescribed an opioid concurrently with benzodiazepines or antipsychotics.
- Exempt certain patients from the safety edits and limits discussed above:
- An individual who is receiving hospice or palliative care
- An individual who is receiving treatment for cancer
- A resident of a long-term care facility
- Any other individual a state elects to treat as exempt
ACS CAN Position
ACS CAN believes that any limits on opioid prescriptions should be based on quality evidence showing that such a limit will improve health outcomes and prevent opioid misuse and abuse. The goal of limits should not simply be a reduction in opioid utilization.
Furthermore, any program limiting the amount, dosage, or number of refills for opioid prescriptions should exempt:
- Cancer patients in active treatment;
- Cancer survivors who continue to receive treatment for pain because of the effects of cancer treatment or the cancer;
- Patients receiving hospice care; and
- Other patients experiencing pain or other symptoms related to a serious illness who are receiving, or would be eligible for, palliative care services.
 42 USC §1396a(oo)
 Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. National Academy of Sciences.
 Miaskowski C, Cooper B, Paul SM, et al. (2012). Identification of Patient Subgroups and Risk Factors for Persistent Breast Pain Following Breast Cancer Surgery. J Pain; 13(12) pp 1172-1187.
 American Cancer Society Cancer Action Network. First Survivor Views Survey Highlights Barriers to Addressing Side Effects of Cancer Treatment. Press Release. October 28, 2019. https://www.fightcancer.org/releases/first-survivor-views-survey-highlights-barriers-addressing-side-effects-cancer-treatment
 American Cancer Society Cancer Action Network. Survivor Views: Pain and Palliative Care; Survey Findings Summary. October 28, 2019. https://www.fightcancer.org/sites/default/files/Survivor%20Views.Pain%20and%20Palliative%20Care%20Polling%20Memo.20191028_FINAL.pdf Additional analysis of Survivor Views data conducted by ACS CAN staff.
 Centers for Medicare and Medicaid Services. State Guidance for Implementation of Medicaid Drug Utilization Review (DUR) provisions included in Section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (P.L. 115-271). August 5, 2019. https://www.medicaid.gov/federal-policy-guidance/downloads/cib080519-1004.pdf
 Sample language used in Medicare policy that is inclusive of survivors: “patients being actively treated for cancer-related pain”. See 42 CFR §423.100, and the discussion in CMS–4182–F, available at https://www.govinfo.gov/content/pkg/FR-2018-04-16/pdf/2018-07179.pdf