According to a 2017 study published in the Annals of Internal Medicine, around 92 million American adults were prescribed opioids in 2015. Although these were legitimate prescriptions, 11 million of those individuals admitted to somehow misusing the medication. Estimates put the number of people with health coverage and with an opioid use disorder for that same year at a million and a half. So the misconception that opioids are only subject to abuse when they’re obtained outside of sanctioned medical channels is just that, a misconception.

A new study published in JAMA Network Open reveals that insurer protocol (private and government) has not been lending itself to curtailing the opioid epidemic ravaging the nation. An important part of pain management is the accessibility of non-opioid medications, but the study showed that insurers often set up the same prescription preapproval requirements and quantity limits for non-opioids as they do for opioid counterparts, which means that individuals seeking relief may not find it any easier to get less addictive drugs.

“…insurers have contributed to the opioid epidemic.”

The study’s senior author is Dr. G. Caleb Alexander, associate professor in the Bloomberg School’s department of epidemiology and co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. “At least unwittingly, insurers have contributed to the opioid epidemic,” he told Modern Healthcare. “Our findings highlight important ways coverage and reimbursement can be better aligned with the evidence base.”

The policies of 50 insurers were analyzed by researchers at the Johns Hopkins Bloomberg School of Public Health, covering a nine-month period in 2016. The pool included 15 Medicaid programs, 15 Medicare Advantage plans, and 20 private insurers. And the condition requiring pain relief was chronic lower back pain.

At a glance, the study showed that the rate of coverage for opioid meds across all plans was 72%, and slightly more than that (75%) for non-opioid drugs. More specifically, Medicare Advantage Plans covered 57% of the opioid prescriptions presented, Medicaid paid for 63%, and the 20 commercial plans gave the OK to opioids on average 77% of the time.

How important are non-opioids in the fight against the deadly epidemic?

Making alternatives to opioids easier to get than opioids might be one way to cut down on use of the highly addictive substance. When it came to the commercial healthcare plans the study researched, the majority of opioid and non-opioid pain relief came with an average copay of $10. But when it came to Medicare Advantage plans, sometimes non-opioids had a higher copay price tag; most opioids fell in the tier 2 or 3 category, while most non-opioids were labeled as tier 2 and therefore required more out of pocket from patients.

“We’ve spent so much time focused on opioids, but they’re just one tool in the toolbox,” Alexander said. “We have to make other tools easier to reach for and use.”

Quantity limits: not a panacea, especially when not reliably used

Perhaps unsurprisingly, when it came to attempts to curtail opioid use, the most frequent tool for that across all healthcare payers was setting quantity limits. Laudably, Medicare Advantage plans employed restrictions on quantity for all of the opioids they covered; commercial insurers added quantity ceilings to 70% of the opioids they paid for, and Medicaid policies did the same in 69% of the cases. Beyond those averages, though, what the study’s researchers found noteworthy was that the limits themselves were sometimes the same for initial opioid prescriptions and refills that followed. And this despite the fact that relatively new legislation stipulates that a first prescription for an opioid cannot exceed 10 days of medication.

“Many of the plans that we examined didn’t have well-developed policies in place to limit their overuse,” Alexander noted.

The Bloomberg School study also revealed that insurers do not often implement step therapy (the method of opioid restriction that involves practitioners first attempting to manage the patient’s pain with non-opioid medications, before trying more addictive drugs). No Medicare Advantage plans looked at in the study included step therapy restrictions; Medicaid plans used this method of curtailment in around 9% of the opioid prescriptions it covered; and the commercial payers the study analyzed only flexed the step therapy muscle on average 4% of the time.

Cigna has a lofty goal and Blue Cross takes on step therapy

However, the study shouldn’t be interpreted to mean that insurers are ignoring the severity of the opioid crisis or shirking their part in ameliorating it. Alexander told Modern Healthcare that some health systems have revised their policies since the study was conducted with an eye on cutting down on opioid misuse. Cigna, for one, made their goal publicly in 2016: to decrease member opioid use by one-quarter by 2019.

And last spring, the Blue Cross and Blue Shield Association developed a new standard for pain management that includes step therapy as normal protocol. This is in line with the Centers for Disease Control and Prevention’s guidance of two years ago that says opioids should not be considered first when a patient presents with pain symptoms.

Alexander, while acknowledging payers’ recent strides in the battle against the opioid epidemic, isn’t wearing rose-colored glasses. “On the other hand, we’ve been watching this epidemic get worse, hidden in plain sight for 20 years,” he said. “I think insurers deserve credit for recent changes, but there’s a lot more that insurers can do.”

This article is provided for educational purposes only and is not offered as, and should not be relied on as, legal advice. Any individual or entity reading this information should consult an attorney for their particular situation. For more information/questions regarding any legal matters, please email or call 310.203.2800.