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Colorado Medicaid changes its policy on opioid drugs in response to crisis

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Opioid drugs will see stricter limits under Medicaid. - STEVE HEAP / SHUTTERSTOCK.COM
  • Steve Heap / Shutterstock.com
  • Opioid drugs will see stricter limits under Medicaid.

According to the Centers for Disease Control and Prevention, 91 Americans died every day in 2015 from an opioid overdose.

The uptick in such deaths hasn't been driven by the growing popularity of heroin alone — even the CDC acknowledges that overprescription of pharmaceuticals is "a driving factor" in the epidemic. Notably, Senate Republicans' last attempt to repeal and replace Obamacare included $45 billion to fight the opioid epidemic, and the Food and Drug Administration and the Justice Department have recently cracked down on pharmaceutical companies that make the drugs.

Now, Colorado's Department of Health Care Policy and Financing is responding to the problem by restricting opioid prescriptions issued through Health First Colorado (state Medicaid). Starting Aug. 1, Medicaid will limit prescriptions for short-acting opioids for those who haven't had one in the past 12 months, allowing a seven-day supply to be filled initially. Patients can get two more seven-day prescriptions, but a fourth will only be available with authorization from the department and "could also require a consultation with a pain management physician from the department's Drug Utilization Review board."

Previously, the department allowed up to a 30-day prescription, and further prescriptions as a doctor permitted. That will still be the case for patients who have had an opioid prescription in the past year. (Though there are some federal limits on the drugs.)

If that seems odd, department spokesperson Marc Williams explains that the idea is to protect people who clinicians refer to as "opioid naive" — or those who haven't had a prescription in at least 12 months. In fighting opioid addiction, state Medicaid, he says, wants to start with "the low-hanging fruit," and prevent newbies from getting hooked.

A department press release notes, "The policy was developed following a department analysis of claims data showing a growing number of Health First Colorado members who have not taken opioids before — or have not taken them for up to one year — once they start opioids, go on to using them more frequently."

On Oct. 1, Medicaid will also limit the strength of opioid drugs. While previously up to 300 Morphine Milligram Equivalents per day were allowed, the cap will now be set at 250 MME, with stronger drugs requiring department authorization, and possibly a consultation with the department's pain management physician.

Department spokesperson Marc Williams clarifies that people on a pain management regime won't be taken off opioids (for instance those in hospice or on palliative care) because those people are on long-acting opioids. People on these programs will have the strength of their medication limited on Oct. 1.

The department's chief medical officer, Dr. Judy Zerzan, says the decision to limit the medications' strength is supported by research that's found that beyond 90 to 120 MMEs there is little effect on pain, and above 300 MMEs "there's really quite a high risk of death from overdose." The department initially only limited the quantity of long-acting opioids, but created the 300 MMEs limit in February 2016. She says Medicaid is slowly stepping down the strength of opioids — another drop could take place in the future — because some people develop a tolerance to the drug and tapering doses too quickly can lead to pain.

Zerzan says patients do have other options. "There are other medications, and those include things like Tylenol and anti-inflammatories that in studies they do have good pain control, we also do cover physical therapy." In fact, she says, Medicaid nearly tripled the reimbursement rate for physical therapy in 2015 in an effort to persuade more providers to offer care to Medicaid patients. Cognitive behavioral therapy, she says, has also shown promising results with pain management.

Editor's note: This story has been updated with a clarification.

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