What Are Medicare Opioid Guidelines?

According to the Centers for Disease Control and Prevention (CDC), more than 106,000 people died from a drug overdose in 2021. That averages to 292 people every day, a rise from 251 overdose deaths per day in 2020. The majority of those deaths were attributable to synthetic opioids like fentanyl, fentanyl analogs, and tramadol followed by semisynthetic opioids like hydrocodone and oxycodone, and then heroin.

The opioid epidemic affects people of all ages. From 2020 to 2021, overdose rates rose across all age groups, including those 65 and older. In 2021, more than a million Medicare beneficiaries had a diagnosis of opioid abuse disorder. Studies in the past have also shown that people under 65 who qualify for Medicare based on a disability have higher rates of opioid overdose than their peers.

To curb the trend, the Centers for Medicare and Medicaid Services (CMS) introduced Medicare opioid guidelines that will be reviewed below.

Opioid Use in Medicare Beneficiaries

Multiple studies have shown a rise in prescription opioid use in Medicare beneficiaries in the past decade.

A 2018 study in the British Medical Journal looked at opioid use data for 48 million people covered by either commercial insurance or Medicare Advantage plans. Over a 10 year period, 26% of all Medicare beneficiaries, and 52% of those that qualified for Medicare based on a disability, used opioids annually. Among all study participants, disabled Medicare beneficiaries had the highest rates of opioid use, the highest rate of long term use, and the largest average daily doses.

A study in the Journal of Managed Care and Specialty Pharmacy in 2019 focused on healthcare claims data for more than 15.5 million beneficiaries on traditional fee-for-service (FFS) Medicare. The researchers used diagnostic codes from these claims to identify cases of misuse and abuse of prescription opioids. Approximately half of all Medicare beneficiaries used at least one prescription opioid during that time. Misuse and abuse were seen at a 1.3% rate and was more prominent in disabled Medicare beneficiaries, accounting for 76.2% of those cases. 

The data seems to suggest that Medicare beneficiaries, whether they are on traditional Medicare or Medicare Advantage, are more likely to be prescribed opioid therapies and are at higher risk for abuse.

SUPPORT Expanded Opioid Use Disorder Treatment

The federal government has taken steps to address the opioid epidemic. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was passed in October 2018. The legislation was multi-pronged and aimed to decrease opioid abuse in a number of ways.

This included, but was not limited to, creation of new and expansion of existing programs to treat substance use disorders, increasing funding for residential treatment programs for pregnant and postpartum women, authorization of grants for states to improve their prescription drug-monitoring programs, expanding the use of telehealth services, and funding research and development of new non-addictive painkillers and non-opioid drugs and treatments. 

For Medicare beneficiaries in particular, SUPPORT had the following impact with most of the following provisions beginning in 2020.

• A new Part B benefit was created that would cover opioid treatment programs (OTPs).
• Participating OTPs needed to be fully certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and enrolled in Medicare.
• Care from an OTP could be administered via telehealth without geographic restrictions that were placed on other types of telehealth services at the time.
• Medicare Part D plans could pay toward opioid use disorder treatments, including methadone.
• Part D plans had to establish drug management programs for beneficiaries considered to be at-risk for opioid use disorder.
• Welcome to Medicare and Annual Wellness Visits had to screen for substance use disorders.

Medicare Part D Policy Changes

Medicare Part D guidelines were introduced in 2019 to further address prescription opioid use. The guidelines have evolved over time. The most recent guidelines in 2022 recommend the following:

• If you receive a new opioid medication for the first time or have not had an opioid medication in a long time (e.g., typically within 60 to 90 days), you may be limited to a seven-day supply. If more medication is needed, a medical provider will need to seek Part D approval through a "coverage determination".
• If you are prescribed long-term opioid medications, you may be required to get your prescriptions from a designated medical provider(s) or pharmacy. The goal is to improve care coordination and to decrease the risk of overprescribing.
  
• A safety alert will be triggered at the pharmacy if you receive a dose or quantity of opioid medication that exceeds a certain limit. Each Part D plan will decide on the parameters that will trigger these safety alerts, i.e., a plan may only set these alerts if you use multiple prescribers or pharmacies for your opioid medications. CMS recommends care coordination when you receive 90 morphine milligram equivalents (MME) or more per day. Some plans may set a cap at 200 MME per day that will require direct communication between the pharmacist and the prescriber before your prescription can be filled.
• A safety alert will be triggered at the pharmacy if you take an opioid medication and a benzodiazepine at the same time. Both classes of medication have addictive potential. Taken together, there is also an increased risk of overdose.

These rules will not apply to everyone. Residents of long-term care facilities, people being treated for cancer-related pain, and beneficiaries in hospice, palliative, or end-of-life care will be exempt from these Part D policy changes.

Summary

The federal government is taking steps to curb opioid use disorder. Although well-intentioned, current opioid prescribing guidelines from CMS could pose some challenges for Medicare beneficiaries trying to fill their medications at the pharmacy, especially for those with chronic pain syndrome.

The goal is not to deny people the medication they need but to provide checks and balances that assure they are receiving appropriate drugs at safe doses. Everyone's medical condition is unique and each treatment plan will need to be tailored to the individual's need. That's why CMS has provided guidelines and not hard and fast restrictions on what can be prescribed.

Preventing opioid use disorder is only part of the plan. Treatment is also needed for the more than 1 million Medicare beneficiaries who already have the condition. Starting in 2020, Medicare expanded Part B benefits to include opioid treatment programs and also lifted telehealth restrictions for anyone with a substance use disorder. Part D plans can now cover opioid use disorder treatments like methadone. It's a start.

If you or someone you know has concern about opioid use, know that Medicare now offers more coverage than it has in the past. Do not hesitate to reach out to your healthcare provider for help.