Opioid addiction has deep roots in the United States. During the Civil War, the Union Army issued nearly 10 million opium pills and nearly 3 million ounces of opium powder.1 Injured soldiers who were given opium for the pain sometimes returned home as addicts. The current opioid epidemic has similar origins—liberal opioid prescribing for pain has led to an epidemic of addiction. Now, just as in the 1800s, the focus appears to be on treating the addiction rather than identifying ways to avoid it.
Medicaid covers nearly 40 percent of the estimated 1.7 million non-elderly adults who have an opioid addiction, according to the Kaiser Family Foundation.2 While Medicaid programs across the country often cover opioid-addiction treatment, but addiction and overdoses are downstream problems. Treatment of addiction can take years—sometimes a lifetime of treatment is required. Although treatment is critically important, likely greater focus on prevention is needed to stop the epidemic.
Many Medicaid programs are starting to track opioid prescriptions, and are encouraging clinicians to limit the dose and duration of those drugs. But limiting access to prescription opioids is usually not enough to prevent addiction. The underlying reasons people start taking opioids should also be addressed. A Medicaid beneficiary who gets cut off from prescription opioids could turn to illegal sources, or transition to street drugs, such as heroin or fentanyl. Root causes for opioid addiction can include chronic or recurrent pain, depression or other mental-health disorders, and socioeconomic factors. If these reasons for drug use are not identified and addressed, it is unlikely that addiction will be prevented and addiction treatment will likely fail.
The average cost to treat an overdose patient in a hospital intensive care unit tops $92,000, according to a 2017 study of 162 hospitals in 44 states.3 Addiction prevention makes financial sense for Medicaid programs. If the addiction goes untreated, beneficiaries can face a higher risk of infectious diseases such as hepatitis C and HIV. They also are more likely to be injured due drug-related accidents or overdoses. Women who become dependent on opioids are more likely to give birth to babies who are addicted to the drug. But strategies aimed at preventing addiction are typically rare in both Medicaid and in commercial insurance.
Seven strategies to add prevention to Medicaid opioid-addiction efforts
Medicaid programs, Medicaid managed care organizations, and Medicaid providers should consider the following strategies to help prevent opioid addiction among beneficiaries:
- Identify and address root causes of opioid use: One of the first steps in preventing opioid abuse is for the clinician to determine why a patient is taking prescription opioids. The underlying cause might be pain, but it also could be related to a mental health disorder or nonmedical use of drugs. If the patient is already addicted, a referral to treatment is essential. Along with addressing the addiction, treatment should include care for the underlying cause.
- Rethink how pain is managed: For beneficiaries who have a chronic pain condition, prevention of opioid addiction can start with the person who writes the prescription. Clinicians should consider how they can help manage a patient’s pain in a comprehensive, multidisciplinary way—rather than just reaching for the prescription pad. Medicaid programs and Medicaid managed care plans should support physician education. Reporting quality measures or incorporating them into payment incentives could help clinicians prescribe opioids according to current, evidence-based guidelines.
- Include alternative pain-management providers in the network: If the underlying cause of opioid use is a pain condition, Medicaid beneficiaries should have access to non-narcotic-based pain-management options. These can include physical therapy, behavioral cognitive therapy, and other non-pharmacologic approaches. If Medicaid doesn’t cover alternative pain treatments, clinicians have few options for reducing opioid prescriptions, particularly if over-the-counter pain relievers don’t work. Medicaid programs should make sure that participating managed care plans cover alternative pain therapies. They should also verify that groups offering those services are part of the provider network.
- Assess the addiction risk: Patients who have severe, long-term pain might not benefit from alternative treatments. Some patients need prescription opioids just to get through the day, and not everyone who takes this medication becomes addicted. But there are ways to manage drug usage, such as screening patients regularly for signs of addiction. Opioid prescriptions should not automatically renew, and dosages should be kept to a minimal level. Rather than prescribing a dosage that will eliminate a patient’s pain, the clinician should consider a lower dosage that alleviates enough pain to allow for an acceptable quality of life, and perhaps return to work.
- Encourage patients to play a part in their pain management: Clinicians and Medicaid managed care organizations should help manage patient expectations and help them understand they have a role to play in managing their own pain. For example, a patient who has severe back pain might benefit from a physical therapy or weight-loss program. Patients who do take opioids should be told about the addiction risk. They should agree to participate in regular and frequent addiction screenings, as well as adhere to the medication regimen prescribed.
- Recover or destroy unused prescription drugs: Physicians should tell patients—along with all caregivers—how to return unused opioids. The top source of abused prescription opioids is pills shared by friends and family members, according to the Centers for Disease Control and Prevention. Moreover, many older patients don’t receive information about what to do with their leftover pills, according a recent survey of more than 2,000 adults between the ages of 50 and 80.4
- Work to improve prescription drug-monitoring databases: Prescription Drug Monitoring Programs (PDMPs) are electronic databases used to gather data about controlled the substances dispensed throughout a state. Accessing a PDMP can be a first step in prevention. Medicaid programs can use the database to see how many prescriptions have been written for opioids, along with the dosage. They can be used to identify clinicians who might be over prescribing, or pharmacies that are filling prescriptions for people who have multiple prescriptions. It also can identify people who pay cash for prescriptions so that Medicaid doesn’t have a claims record of them. However, accessing real-time data from the state databases can be challenging, according to a new report from Deloitte’s Center for Health Solutions that examines what health plans and pharmacy benefit managers (PBMs) are doing to address the opioid epidemic. While almost all states have a PDMP, only 13 require that prescribers access the patient’s prescription history, and 36 states have barriers that can make it difficult to use the database to curb abuse, according to data from the US Centers for Medicare and Medicaid Services (CMS).5 PDMPs generally do not indicate why the clinician ordered the pills, or include any information about the patient’s diagnosis. That can make it difficult to know if a patient has a legitimate, evidence-based prescription.
State Medicaid programs, along with Medicaid managed care organizations and providers, should take a root-cause approach to determine why a beneficiary began taking opioids and should ensure that if opioids are needed to manage pain, they are prescribed according to current guidelines and their use is monitored. We should put as much focus on addiction prevention as we do on treatment.
1 Smithsonian.com, Inside the story of America’s 19th-Centrury Opiate Addiction, January 4, 2018
2 Kaiser Family Foundation, Medicaid’s role in addressing the opioid epidemic, February 2018.
4 National Poll on Healthy Aging, University of Michigan, July 2018
5 CMS, October 2017: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/downloads/2016-dur-summary-report.pdf