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Yale researchers studied 10 years of Medicare data and concluded that the program’s plans do not adequately address the opioid crisis in the United States.

Although opioids are highly addictive and can lead to fatal overdoses, they are still often prescribed in large doses over long periods of time. In a paper published on Oct. 10 in the Annals of Internal Medicine, researchers found that most Medicare plans place few restrictions on potentially addictive opioid prescriptions.

Medicare is the single largest insurer of adults over the age of 65 in the United States, said Elizabeth Samuels, postdoctoral fellow at the Yale School of Medicine and first author of the study. Studying Medicare’s pattern of coverage is useful, as it reflects coverage of other insurance providers nationwide, she added.

“The policy implication of our work is the finding that insurance plan formularies have a potentially greater role to play in combatting our opioid epidemic,” said Sanket Dhruva, a co-author of the study.

Medicare plans follow different lists of covered drugs, known as formularies. Individual formularies have the freedom to determine their own coverage and limitations in a private process.

The researchers studied Medicare’s prescription drug plan files over a 10-year period, focusing both on the drugs covered by plans and on any limitations on their prescription. They analyzed both the coverage and restrictions that different formularies placed on opioids, which are commonly used as painkillers. The researchers found that Medicare formularies increased coverage of prescription opioids from 2006 to 2015.

When prescribed in limited doses over short timeframes, opioids are not as dangerous, Samuels said. It is when opioids are prescribed in increasing dosages over long periods of time that problems arise, Dhruva said.

The Centers for Disease Control and Prevention recommends maximum dosage limits on prescription opioids. Those recommendations are nonbinding, however, and formularies often disregard them. According to the study, only 13.3 percent of covered Medicare prescriptions met the CDC’s recommended dosage limitations in 2015. The researchers hope these findings lead the federal government to reconsider Medicare coverage and better address patient safety, said Joseph Ross, professor at the Yale School of Medicine and co-author of the study.

On the flip side, Medicare formularies have increased limitations on the quantity of certain opioids that can be prescribed at a given time. One third of drug combinations remain unrestricted, Dhruva said. This includes some drugs that are highly implicated in overdoses, such as hydrocodone, Samuels said. Currently, she added, many states are trying to pass restrictions on opioid prescriptions; in order to fully address the crisis, formularies must cooperate and pass their own restrictions.

The researchers stressed that there are multiple ways to reform the current prescription limitations system. In addition to quantity control limitations, formularies are also able to restrict health practitioners’ ability to prescribe opioids without first exploring other options, Samuels said. Unfortunately, she added, while the CDC and physicians in general advocate for non-opioid forms of pain control, there is a limited number of alternatives. But in many cases, alternatives to opioids are not considered prior to prescription, Dhruva said.

Samuels said a variety of historical factors contribute to the prevalence of prescription opioids. When prescription opioids were first introduced to the United States, it was not widely clear that they could lead to addiction. At the same time, there was a push across the health care sector to prescribe pain medication more freely, she added.

“There was a large move by pharmaceutical companies when opioids were first introduced to the market to say that these prescription medications were not addictive by spreading a lot of false information about them,” Samuels said.

Today, however, there is increased awareness of prescription opioids’ potential to cause addiction or even death, Dhruva said.

On Thursday, President Donald Trump declared the opioid epidemic a public health emergency. Thus far, the response to the announcement has been mixed with some in the health care community criticizing the lack of funding allocated to addressing the crisis.

“You know I think that those of us who are harm-reduction advocates and really dedicated to addressing the lives lost to opioid use disorder were hoping that his announcement would be used to mobilize resources,” Samuels said. “I think that while he made a public announcement, the resources and meaningful action that should be paired with that was lacking.”

According to the American Society of Addiction Medicine, over two million Americans suffer from a substance use disorder involving prescription pain relievers.

Maya Chandra | maya.chandra@yale.edu