A pharmacist at Mayo Pharmacy in Bismarck, N.D., reviews completed drug orders in January. Advocates, providers, medical groups and state lawmakers are pushing for insurers to cover non-opioid painkillers. (Photo by Michael Achterling/North Dakota Monitor)
More states are requiring their Medicaid programs and health insurers to cover non-opioid painkillers as an alternative to opioids, which can be cheaper for insurers but are also more addictive for patients.
Advocates, providers, medical groups and state lawmakers are pushing for equal coverage. That means prohibiting insurers from charging higher copays for non-opioids than for opioids, and prohibiting them from requiring prior authorization or step therapy — meaning patients must try other medications first — before paying for non-opioid drugs.
At least eight states have enacted such laws: Arkansas, Illinois, Louisiana, Maine, Massachusetts, Oklahoma, Oregon and Tennessee. In states still considering legislation, the effort has been bipartisan, driven by lawmakers in Democratic-controlled states like Colorado and New York, as well as Republican-leaning states like Kentucky and Missouri.
The issue has gained traction in recent years as leading medical associations such as the American Society of Regional Anesthesia and Pain Medicine have urged doctors not to prescribe opioids as a first-line treatment for pain. There is now bipartisan legislation introduced The initiative, passed in Congress last year, aims to improve Medicaid Part D enrollees’ access to non-opioid pain medications. It was referred to a committee.
Dr. Patrick Giam, president of the American Society of Anesthesiologists, said the organization “believes it is important that insurance plans make non-opioid therapies as accessible to patients as opioid-based therapies.”
Non-opioid pain medications include prescription anti-inflammatory NSAIDs such as naproxen and ibuprofen, nerve blocking injections, certain antidepressants, antiseizure medications, acetaminophen, and other medications. Opioids include oxycodone, codeine, morphine and fentanyl. The U.S. Food and Drug Administration has promoted opioid-free alternatives for pain relief.
Last year, The agency agreed a modern drug called suzetrigine under the brand name Journavx, the first non-opioid painkiller in a modern class of analgesics. The medication, available in tablet form, can be prescribed for acute pain following operations or injuries. Vertex Pharmaceuticals, the manufacturer, is one of the funders of Voices for Non-Opioid Choices, which lobbied for the bills.
In Missouri, where GOP-sponsored legislation would prohibit insurance companies from denying coverage for a non-opioid prescription or charging a higher copay for a non-opioid, according to the Missouri Insurance Coalition argued that the measure would boost healthcare costs and effectively create a “monopoly” for Journavx. Any tablet can cost about $15 per tablet out of pocket. However, lawmakers referred to opioid-free alternatives.
Why non-opioids often cost more
“Newer non-opioid medications coming onto the market are more expensive than opioids because there is no generic alternative yet,” said Sterling Elliott, an Illinois clinical pharmacist and lecturer at Northwestern University Feinberg School of Medicine and board member of Voices for Non-Opioid Choices.
“The price of many things is so high because the price of generic opioids is so low. Generic opioids are among the cheapest drugs found in the American drug supply,” Elliott said. “When you get a new entrant into the pain market, the market factors are set to drive the price up.”
Elliott added that some insurance plans don’t cover prescription NSAIDs like ibuprofen because they would prefer people to pay out of pocket for lower-strength, over-the-counter versions of these drugs.
In New York, Democratic Assemblyman Phil Steck, co-sponsor of a bipartisan bill on which there was no hearing, said challenging insurance companies would not be effortless.
“They’re trying to tell insurers what to do,” Steck said. “These are usually difficult undertakings. … Our experience is that the [legislature’s] Dealing with the insurance committee is very difficult and therefore has not been pursued as intensively as we would have liked.”
Non-opioid coverage can vary widely depending on the insurance plan, explained clinical pharmacist Emma Murter, co-chair of the Society of Pain and Palliative Care Pharmacists’ advocacy committee.
“There are so many [non-opioid] Medications that can be used for chronic pain,” Murter said. “It’s not gut-level what’s covered and what’s not. It’s very Wild West, chaotic.”
When it comes to filling prescriptions, Murter said she often has to fight and appeal with insurance companies “for some of these non-opioid therapies.”
Dima Qato, an associate professor of clinical pharmacy at the University of Southern California, said non-opioid prescription painkillers are appearing less frequently on insurance companies’ “preferred” drug lists. Because insurers may favor the cheaper opioids, this may result in higher copays or consumers having to pay more out of pocket.
That was the case with Chris Fox, the Washington lobbyist who serves as executive director of Voices for Non-Opioid Choices. Fox has traveled to state capitals across the country to advocate for the bills. Recently, he had a personal experience with pain medication after oral surgery.
“For everything except the non-opioid, my expectation of paying out of pocket was $0,” he said. He was charged $30 out of pocket for the non-opioid.
His oral surgeon was not familiar with the availability of the modern, first-in-class non-opioid suzetrigin, Fox added. When he asked the doctor for a prescription for it, the surgeon wrote it out, but also prescribed an opioid and an antibiotic.
“He prescribed me hydrocodone just in case because he wasn’t familiar with it [suzetrigine]said Fox.
Addiction prevention
While on the phone with Stateline, Fox drove to the local sheriff’s office to drop off the hydrocodone he hadn’t taken after his surgery.
“I would say we have neglected the opportunity to prevent opioid addiction where we can, and that is in those patients who develop a new persistent pattern of opioid use after exposure to an opioid that they are receiving for medical reasons,” Fox said.
Although opioid overdose deaths have declined, about 200 Americans still die from the drugs every day.
Healthcare professionals in hospitals are also struggling with lower reimbursement rates for some non-opioids.
Dr. Joseph Smith, an anesthesiologist at a Virginia surgical center who has practiced for three decades, pointed to a nerve-blocking pain pump as an example. Administering a brand-name version of the drug could cost up to $400 for all the equipment, he said. Like Elliott, Smith sits on the board of Voices for Non-Opioid Choices.
“So the hospital says, ‘Well, I can spend $400 or 25 cents on a numbing pill,'” Smith said.
Smith treats many adolescent adolescent athletes with sports injuries. Research has shown that consuming narcotics after surgery can boost the risk of addiction.
“My goal when I bring a 14- or 15-year-old here is that they never try a narcotic and are never exposed to narcotics,” he said.
Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.
This story was originally produced by State borderwhich is part of States Newsroom, a nonprofit news network that includes West Virginia Watch, and is a 501c(3) public charity supported by grants and a coalition of donors.
