State Medicaid agencies around the country are limiting how many opioids providers can prescribe in an effort to curb the disproportionate number of beneficiaries who are at risk of overdose and death.
North Carolina, for example, found that while the Medicaid population represented approximately 20% of the overall state population (PDF), it accounted for one-third of drug overdose deaths, the majority of which were caused by prescription opioids.
In 2013, at least one Colorado resident died every day from unintentional drug poisonings. Since 2014, Colorado has limited short-acting opioid prescriptions to a maximum of four tablets a day or 120 tablets per 30 days. In February, it introduced a new policy that also limited use of long-acting opioids.
It's one of 20 states that is limiting prescriptions. It's too early to access the patient benefits, but the agencies already are seeing an upside.
Colorado has saved $629,000 as a result of the 2014 policy, according to state data.
“State Medicaid agencies need to make policies because we're using taxpayer dollars and are a safety net for a large number of the population,” said Dr. Judy Zerzan, chief medical officer for the Colorado Department of Health Care Policy and Financing, the state's Medicaid agency.
Starting Oct. 1, Medicaid providers in Nebraska, a state that doesn't have a particularly high rate of opioid overdose, will limit prescribing five pills a day or 150 tablets per 30-day period for short-acting opioids.
“We're trying to head something off before it starts,” said Calder Lynch, the state's Medicaid director.
Pending CMS approval, the state also plans to add coverage for peer addiction specialists, he said.
Providers are overall supportive of the limitations. In fact, many of them developed the policies in their states, but some doctors are less enthusiastic.
“No one likes to have arbitrary numbers placed on them,” said Dr. Robert Wergin, chair of the American Academy of Family Physicians board. “There will likely be individual circumstances where they'll need to go beyond the limit.”
There will likely be some patient push back, said Dr. John Massey, an interventional pain physician in Nebraska.
“Initially, patients are going to feel worried since what they think has been effective will not be an option anymore,” Massey said. “But in the long run, they'll see it will help improve the management of their pain.”
Robert Twillman, executive director of the American Academy of Pain Management, a group that represents pain physicians and receives funding from painkiller manufacturers such as Purdue and Teva Pharmaceuticals, said he wasn't crazy about the limits.
“You either have to build in many escapes or exceptions for cases to the point that the policy is ineffective or if you don't, you limit access to those who may need the drugs,” Twillman said.
Experts agree that for any efforts to succeed, patient expectations must change.
“We live in a culture that believes in being pain free, even from minor aches,” said Dr. Mitra Ahadpour, medical officer at the Center for Substance Abuse Treatment at SAMHSA. “A little bit of pain is Ok.”
Medicaid agencies have exempted cancer and sickle cell patients and will allow doctors to argue for their own exemptions.
Shawn Lang, who leads a Connecticut overdose prevention task force, would like to see opioids return to their intended initial use: for cancer patients at the end of life. She thinks doctors should be trained in medical school on the issue.
Wergin agreed that education is key, not only for doctors, but for patients. He said the limitations should be just one of several methods used to battle the opioid epidemic. “It's one tool and it's not going to be the one way to solve the problem,” Wergin said.