Last year, a patient using Medicare’s prescription drug program managed to receive an unbelievable amount of opioids: In total, this patient got 46 different prescribers and 20 pharmacies to dole out the drugs. In just August, this patient managed to receive 11 different opioid prescriptions from eight prescribers and six pharmacies across five states — a potential indication that no one involved checked the patient’s prescription history.
This is an extreme case, but it’s one example cited in a new report by the Office of Inspector General (OIG) at the US Department of Health and Human Services as evidence that the Medicare prescription drug program, Part D, is essentially funding a lot of opioid prescriptions that are fueling the ongoing drug overdose epidemic. In short, Part D is likely enabling potentially tens of thousands of opioid users in getting the drugs so they can misuse or resell them.
The report produced several key findings for Medicare Part D beneficiaries and their opioid use in 2016:
- About one in three beneficiaries, or 14.4 million people, received at least one opioid prescription.
- More than 11 percent of beneficiaries, or 5 million people, received opioids for three months or more. The research shows the risk of dependence — and potentially addiction — significantly increases for patients who get opioids for three months or more.
- Excluding people in cancer or hospice care, about 1 percent of beneficiaries — more than 500,000 people — got more than 120 mg of morphine equivalent dose (MED) in opioids a day for at least three months. The Centers for Disease Control and Prevention (CDC) strongly warns against prescribing more than 90 mg except in extreme circumstances, due to the increased risk of addiction and overdose at higher levels.
- Almost 90,000 beneficiaries are at “serious risk of opioid misuse or overdose”: Nearly 70,000 appeared to be getting “an extreme amount of opioids,” or 240 mg MED or more a day over 12 months. And more than 22,000 appeared to be doctor shopping, when patients go to various doctors and various pharmacies to try to obtain as many opioids as possible.
- More than 400 prescribers consistently displayed questionable prescribing patterns for beneficiaries at serious risk of opioid misuse or overdose. And nearly 116,000 ordered opioids for at least one beneficiary at serious risk.
The report suggests that there is a lot more that Medicare could be doing to monitor both patients and doctors for excessive prescribing practices. It specifically points to better use of prescription drug monitoring programs, which establish databases that prescribers can use to more easily track patients who are getting an excessive amount of opioids.
All but one state (Missouri) have a prescription drug monitoring program, although some states have more robust systems. A recent study published in Addiction found that the states with more robust monitoring programs had significantly fewer opioid painkiller overdose deaths than those with less robust programs.
One big caveat to the report: Not all the beneficiaries and prescribers that it calls out were necessarily doing something wrong. It is entirely possible that many of these patients and doctors — even those getting or ordering an extreme amount of drugs — have a legitimate medical reason for doing so. The OIG is merely warning that there are so many of these cases that chances are there’s still a lot of unscrupulous prescribing going on.
The report’s findings come at a crucial time in the crisis. It’s currently estimated that up to 65,000 people died of drug overdoses in the US last year alone — more than the American casualty counts for the entire wars in Vietnam and Iraq. This is now the deadliest drug overdose crisis in US history. For an important federal health program to be potentially contributing to the crisis is very bad.
Prevention and treatment can each play a role to stop the opioid crisis
Reducing the flow of opioids from doctors to patients is key to stopping the opioid epidemic.
The opioid epidemic began in the 1990s, when doctors became increasingly aware of the burdens of chronic pain. Pharmaceutical companies saw an opportunity, and pushed doctors — with misleading marketing about the safety and efficacy of the drugs — to prescribe opioids. Doctors followed suit — in some states, writing enough prescriptions to fill a bottle of pills for each resident. With all this overprescribing, some patients became addicted to the drugs, while other patients left them out for their children to steal and misuse, gave away extra pills to friends and family, or sold them in the black market.
Addressing this is key to stopping the drug overdose crisis: If you can cut off new patients who don’t really need opioids from getting the drugs, you will stop some of them from getting addicted — and potentially stop the problem from getting worse. That’s why some states have focused on reducing the number of prescriptions over the past several years — by, for example, telling doctors (sometimes with the threat of the law) to be more careful in how they prescribe the drugs.
Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being told to give more thought to their prescriptions.
There are limits to prevention: With the existing population of opioid users, cutting them off from painkillers could be dangerous. If someone is suddenly yanked from a high dose of opioids, they could undergo painful withdrawal. (This is why experts say careful tapering is necessary for a patient getting off opioids — to ensure the process is as painless as possible.) Or users could decide that, rather than deal with that pain, they’re going to get other opioids, such as heroin or fentanyl — which would lead to even worse outcomes, since both heroin and fentanyl are more potent and, therefore, deadlier than painkillers.
That’s why it’s important to pair prevention efforts with drug treatment.
As Stanford drug policy expert Keith Humphreys told me, there are essentially two populations with two different problems. On one hand, you have the current “stock” of opioid users who are addicted; the people in this population need treatment or they will simply find other, potentially deadlier opioids to use. On the other hand, not doing anything to stop new generations of potential drug users from accessing and misusing opioids would enable a new “flow” of people struggling with addiction.
So far, the government has focused largely on the prevention side — getting doctors to reduce the amount of opioids they prescribe every year since 2010, although the amount of opioids prescribed per person in 2015 was still more than triple what it was in 1999.
But drug treatment remains woefully underfunded. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country, particularly rural counties, lacking affordable options for treatment.
So while the OIG report points to one problem that needs addressing, there’s another equally important issue that needs to be addressed to stop the tremendous amount of death that’s come from this crisis.