Study shows Medicare and Medicaid still too loose about paying for opioid painkillers

Posted on: October 10th, 2017 by sobrietyresources

By David Heitz

Our most vulnerable populations continue to receive opioids at high doses under the Medicare Part D program, even though private insurers already have taken steps to curb such practices.

Powerful opioid painkillers may be appropriate in rare cases, for the short-term, or for people with terminal illness. But the U.S. Centers for Disease Control and Prevention (CDC) has emphasized they should only be used as a last resort.

“Despite increased formulary restrictiveness, unrestrictive coverage persisted for many opioids, especially at high doses, including for drugs commonly associated with overdose,” concluded the authors of the study published Monday in Annals of Internal Medicine. (1)

The paper marked the first time such an analysis was conducted among Medicare patients.

Led by researchers at Yale School of Public Health, the team analyzed data from the Centers for Medicare and Medicaid Services, or CMS. CMS is the largest third-party payer in the U.S.

Medicare serves the elderly; Medicaid serves the poor. Both are government programs.

“The researchers compared coverage for all available doses of commonly used short- and long-acting opioid medications except for methadone,” Annals reported in a news release. “They found that more than two thirds of drug-dosage combinations had no opioid prescribing restrictions in 2006 and 2011 and approximately one third had no restrictions in 2015.

“While quantity limits and prior authorization to restrict daily allowable prescribed dosing increased over the years, unrestrictive coverage persisted for many opioids.” (2)

How did this happen?

One reason stands out like a sore thumb – and a staggering example of bureaucrats not seeing the forest for the trees.

CMS limits number of opioid pills dispensed, but not doses

“Medicare Part D formularies increasingly used quantity limits and, to a lesser extent, prior authorization to restrict daily allowable prescribed dosing of prescription opioids between 2006 and 2015,” the authors reported.

It goes without saying that a 90-day supply of a medication at 250 mg is not the same as a 90-day supply of a medication at 500 mg.

Apparently, the bureaucrats did not think of this when they wrote Medicare Part D guidelines.

“Despite increased formulary restrictiveness, unrestrictive coverage persisted for many opioids, especially at high doses, including for drugs commonly associated with overdose,” the authors concluded.

The Medicare Part D program also applies to people on Medicaid.

So, for the most part, the people being prescribed these high levels of opioids – the same opioids causing dangerous overdoses in just about every town in America – are elderly and poor.

What’s more, as Medicaid or Medicare recipients, there are alternative pain treatments available under their coverage.
The Social Security Act Section 1905 specifically included a provision for covering alternative therapies, leaving it open ended enough to stand the test of time.

It reads, “Other diagnostic, screening, preventive, and rehabilitative services, including… any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.” (3)

However, most states don’t actively point participants in this direction, according to one watchdog organization.

A few facts about pain and Medicaid: Where are we headed?

According to the National Academy for State Health Policy:
• People on Medicaid are prescribed opioids at a disproportionately higher rate than also other Americans. They are also  more likely to overdose
• Less than half of state Medicaid agencies have taken steps to encourage or require non-opioid pain relief methods.
• “Medicaid agencies are faced with important policy considerations, including budget constraints that make covering additional services difficult and provider and beneficiary educational needs to raise awareness on when these services may be appropriate,” according to NASHP.
• “The evidence base for or against non-pharmacological alternatives will become more robust as more Medicaid agencies implement programs encouraging the use of these services,” NASHP predicted. (4)
Private insurers find success limiting opioid prescriptions

“A private insurer showed that implementing prior authorization, quantity limits, and provider–patient agreements was associated with a 15 percent decrease in opioid prescribing,” the research letter published Monday noted.

NASHP urges third-party payers, as well as CMS, to make it easier to access alternative therapies.

In their report, “Chronic Pain Management Therapies in Medicaid: Policy Considerations for Non-Pharmacological Alternatives to Opioids,” the authors cite medical research showing non-opioid pain medications are at least somewhat effective.

“For example, a systematic review found that Cognitive Behavioral Therapy (talk therapy) had small to moderate effects on pain, disability and mood immediately post-treatment when compared to usual treatment,” they wrote.
“Similarly, a systematic review found that acupuncture may benefit people with osteoarthritis,” they continued. “The systematic reviews also suggest lower costs for patients experiencing spine pain who received chiropractic care, although the included studies had many methodological limitations.
For the most part, Big Pharma funds medical research in this country. It’s not in their best business interests to fund research into non-pharmacological alternatives to pain.

“The cost effectiveness of alternative pain management services compared against conventional treatments has not been adequately studied,” the authors of the NASHP report explained. “As more evidence becomes available, state Medicaid agencies can better evaluate which services should be included as a coverage benefit.

“These coverage decisions may ultimately vary based on the type and location of the pain.”
One more reason why it’s not your fault

“Addiction is not your fault” might be all the catchphrase these days, but for people addicted to opioids, it absolutely is true and they need to know that it’s true.

Addiction often is perpetuated by a cycle of shame, regardless of how a person became addicted in the first place. People who end up dependent on opioids after being prescribed them by a doctor simply don’t relate to “addict.” In fact, they resent it.

“As shown by formulary coverage of hydrocodone–acetaminophen, formularies tended to be
less restrictive at higher doses, largely because they maintained identical quantity limits
regardless of dose,” the researchers of the study published in Annals emphasized.

“This factor allowed for higher prescribed MMEs (morphine milligram equivalents) per day. Given that higher doses are associated with higher overdose rates, limiting prescribed MME per day or requiring prior authorization or step therapy for high-dose opioids may facilitate better adherence to Centers for Disease Control and Prevention prescribing recommendations.

“Because formulary coverage directly affects prescribing, our study suggests that formularies
present an underused opportunity to restrict opioid prescribing.”

The research, presented in the form of a letter, was signed by Dr. Elizabeth A. Samuels of Yale University, Yale New Haven Hospital, and Veterans Affairs Connecticut.

If you or someone you know just can’t get off painkillers, or maybe have turned to heroin, do not stop fighting for your life. You didn’t get yourself into this mess to begin with.

Professional help getting off painkillers is more affordable than you might think, and often covered by insurance. Reach out to someone or someplace you trust today.


1. Samuels, E. et al. (2017, Oct. 10). Medicare Formulary Coverage Restrictions for Prescription Opioids, 2006-2015. Annals of Internal Medicine. Retrieved Oct. 10, 2017, from
2. Annals of Internal Medicine. (2017, Oct. 3). A substantial number of opioid-dosage combinations have no prescribing restrictions under Medicare formulary. Annals news release.
3. Social Security Act. Section 1905. Retrieved Oct. 5, 2017, from
4. Dorr, H. et al. (2016, August). Chronic Pain Management Therapies in Medicaid: Policy considerations for non-pharmacological solutions to opioids. National Academy for State Health Policy (NASHP). Retrieved Oct. 6, 2017, from


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