A pharmacist at Mayo Pharmacy in Bismarck, North Dakota, reviews completed pharmaceutical orders for January. Advocates, providers, medical associations and state lawmakers are pushing for insurers to cover nonopioid pain medications. (Photo: Michael Achterling/North Dakota Monitor)
More and more states are requiring their Medicaid programs and health insurance companies to cover nonopioid pain medications as an alternative to opioids, which can be cheaper for insurers but also more addictive for patients.
Advocates, healthcare providers, medical associations and state lawmakers are pushing for coverage parity. This means prohibiting insurers from charging more for non-opioid drugs than for opioids, and prohibiting them from requiring prior authorization or staged therapy – requiring patients to try other drugs first – before including non-opioid drugs.
At least eight states have passed such laws: Arkansas, Illinois, Louisiana, Maine, Massachusetts, Oklahoma, Oregon and Tennessee. In states still considering legislation, the effort has been bipartisan, pushed by lawmakers in Democratic-leaning states such as Colorado and New York and Republican-leaning states including Kentucky and Missouri.
The issue has gained momentum in recent years as leading medical societies, such as the American Society of Regional Anesthesiology and Pain Medicine, have urged doctors not to prescribe opioids as a first-line treatment for pain. Meanwhile, bipartisan legislation introduced in Congress last year aims to expand access to non-opioid pain medications for Medicaid Part D enrollees. The matter was referred to the committee.
Dr. Patrick Giam, president of the American Society of Anesthesiologists, said the organization “believes it is important that insurance plans provide patients with the same availability of non-opioid therapies as opioid-based therapies.”
Non-opioid pain medications include prescription anti-inflammatory NSAIDs such as naproxen and ibuprofen, nerve blocking injections, some antidepressants, anticonvulsants, acetaminophen, and other medications. Opioids include oxycodone, codeine, morphine and fentanyl. The U.S. Food and Drug Administration encourages the utilize of non-opioid alternative pain relievers.
Last year, agency approved a novel drug called suzetrigine, available under the brand name Journavx, the first non-opioid painkiller in a novel class of painkillers. The medicine, available in tablets, can be prescribed for acute pain after surgery or injury. Manufacturer Vertex Pharmaceuticals is one of the founders of the Voices for Non-Opioid Choices initiative, which lobbies for the laws.
In Missouri, where GOP-sponsored legislation would prohibit insurance companies from denying coverage for a prescribed non-opioid drug or requiring a higher copay for a non-opioid drug, Missouri Insurance Coalition he argued that this measure will enhance health care costs and effectively create a “monopoly” for Journavx. Any tablet can Cost about $15 per pill out of pocket. However, legislators pointed to non-opioid alternatives.
Why non-opioids often cost more
Newer non-opioid drugs entering the market are more steep than opioids because there is no generic alternative yet, explained Sterling Elliott, a clinical pharmacist and lecturer at the Feinberg School of Medicine at Northwestern University in Illinois and a board member of Voices for Non-Opioid Choices.
“The price of many products is so high because the price of generic opioids is so low. Generic opioids are among the cheapest drugs you can find in the U.S. pharmaceutical supply,” Elliott said. “When a new entrant enters the painkiller market, market factors are configured to drive up the price.”
Elliott added that some insurance plans don’t cover prescription NSAIDs like ibuprofen because people prefer to pay out-of-pocket for lower-strength, over-the-counter versions of these drugs.
In New York, Democratic Assemblyman Phil Steck, co-author of a bipartisan bill that has not received a hearing, said challenging insurance companies is not basic.
“You’re trying to tell insurers what to do,” Steck said. “These are usually difficult undertakings… Our experience shows that… [legislature’s] The insurance commission is very difficult to deal with, so it hasn’t been dealt with as often as we would have liked.”
Non-opioid insurance coverage can vary significantly depending on the insurance plan, explained clinical pharmacist Emma Murter, who co-chairs the Society of Pharmacists’ Pain and Palliative Care advocacy committee.
“There are so many of them [non-opioid] medications that can be used to treat chronic pain,” Murter said. “It’s not obvious what is and what isn’t. It’s a very wild, disordered wild west.”
Murter stated that when it comes to filling prescriptions, she often has to “fight and appeal for some of these non-opioid therapies” with insurance companies.
Dima Qato, a professor of clinical pharmacy at the University of Southern California, said non-opioid prescription painkillers are less popular on insurance companies’ “preferred” drug lists. Because insurers may favor cheaper opioids, which could result in higher copayments or consumers paying more out of pocket.
That was the case with Chris Fox, a Washington lobbyist who serves as executive director of Voices for Non-Opioid Choices. Fox traveled to state capitols across the country to lobby for the bills. He recently had personal experience with pain medications following oral surgery.
“For everything except non-opioid medications, I expected to have $0 out-of-pocket,” he said. He paid $30 out of pocket for the non-opioid medication.
Fox added that his oral surgeon was not familiar with the availability of the novel, first-in-class, non-opioid suzetrigine. When he asked his doctor for a prescription for this drug, the surgeon wrote it out but also prescribed an opioid along with an antibiotic.
“He prescribed me hydrocodone just to be on the unthreatening side because he wasn’t very familiar with the drug [suzetrigine]– said Fox.
Addiction prevention
Speaking to Stateline by phone, Fox was on his way to the local sheriff’s office to return the hydrocodone he had not taken after surgery.
“I would say that we have neglected the opportunity to prevent opioid addiction where we can, which is in those patients who develop a new, persistent pattern of opioid use after exposure to a medically given opioid,” Fox said.
Although opioid overdose deaths have declined, these drugs still kill approximately 200 Americans a day.
Healthcare workers in hospitals also face problems with lower reimbursement rates for some non-opioid medicines.
Dr. Joseph Smith, an anesthesiologist at a surgical center in Virginia who has been in practice for thirty years, gave the example of a nerve-blocking pain pump. He added that administering a brand-name version of the drug could cost up to $400 for all the equipment. Smith, like Elliott, serves on the board of Voices for Non-Opioid Choices.
“So the hospital says, ‘Well, I can spend $400 or 25 cents on a drug pill,'” Smith said.
Smith treats many teenage teenage athletes with sports injuries. Studies have shown that taking drugs after surgery can enhance the risk of addiction.
“My goal when I get a 14-year-old or 15-year-old here is for them to never try a drug or be exposed to a drug,” he said.
Stateline reporter Nada Hassanein can be reached at: nhassanein@stateline.org.
This story was originally produced by State linewhich is part of States Newsroom, a nonprofit news network that includes Pennsylvania Capital-Star, and is supported by grants and a coalition of donors as a 501c(3) public charity.
