Rates of opioid prescribing dropped nearly twice as quickly for Medicaid patients than for commercially insured patients over the past two years, according to data from the athenahealth network — a sign of how population trends and physician biases may be affecting the public health epidemic.
An analysis of prescribing patterns from more than 2,900 primary care providers found that the number of Medicaid patients with opioid prescriptions fell from 15 to 12 percent — a 20 percent drop, in relative terms — between spring 2014 and spring 2016. The number of commercially insured patients with opioid prescriptions dropped by half that amount — a relative 10 percent during that same period.
Among uninsured patients in the same sample, opioid prescribing rates fell by a relative 12 percent.
Experts in addiction note that a variety of influences can impact prescribing habits. But they also spotlighted a few potential reasons for the big disparity in opioid reduction:
1. Medicaid patients were more likely to be on opioids in the first place
Medicaid patients make up 70 million low-income Americans across the United States, or 16 percent of the total patient population. And those patients are generally sicker and more likely to be disabled than people who are privately insured.
About 15 percent of Medicaid patients qualify for coverage based upon a disability. The Centers for Medicare and Medicaid Services has noted that physicians prescribe opioids for Medicaid patients at twice the rate they do for privately insured patients.
That means providers who are trying to reduce their opioid prescribing rates are likely to focus their efforts on this at-risk population, says Anupam B. Jena, M.D., Ph.D., a professor at Harvard Medical School and physician at Massachusetts General Hospital, who recently published research analyzing opioid prescribing to Medicare patients.
And while it's generally good news that the Medicaid population is receiving fewer opioids, Jena notes, that drop might also reflect some problematic trends in opioid prescribing.
2. Medicaid patients more likely to receive opioids they don't need
Across a multi-state Medicaid database in 2010, researchers at the Centers for Disease Control and Prevention found that 40 percent of opioid prescriptions to Medicaid patients were given inappropriately. The problems included overlapping prescriptions of opioids and benzodiazepines, increasing daily doses to a level higher than the diagnoses required, and writing long-term opioid prescriptions for short-term acute pain.
In addition, compared to all patients on opioids, Medicaid patients were disproportionately more likely to overdose, whether on drugs received through legal prescriptions or on the street. One five-year study by the Washington State Department of Health determined that Medicaid recipients represented 45 percent of opioid-related overdoses in that state.
Given these statistics, Jena says, providers have been motivated to reduce opioid prescribing in the Medicaid population in particular.
Indeed, the CDC issued a bulletin in January 2016 emphasizing Medicaid's role in curbing the epidemic — and advising physicians to make a greater effort to identify at-risk patients and treat them for mental health and substance use disorders.
At the state level, governors and lawmakers from both political parties have taken up that charge, passing Medicaid-specific policies to address opioid prescriptions. Arizona and Massachusetts recently required their state employee insurance plan and Medicaid programs to limit narcotic painkiller prescriptions.
Some have warned that those restrictions could cause patients to suffer — as could some other state policies around alternative treatments for pain and addiction. A recent General Accounting Office study found that some states limit Medicaid patients' access to medication-assisted treatment as they wean off opioid prescriptions.
But at least nine states this year adopted requirements that Medicaid pay for all medically recommended addiction services.
3. Unconscious bias could affect prescribing rates
Some addiction experts warn that widespread attention to the opioid epidemic might be having another negative effect: encouraging physicians to bring outside biases and influences into their treatment decisions.
A doctor could have preconceived ideas about which patients are likely to face complications, misuse pills, or become long-term opioid users, says Jena — and could therefore be less likely to prescribe opioids to someone who fits that profile.
"And my guess," Jena says, "is that those patients are more likely to be in a Medicaid population."
"No one thinks that how they're practicing is biased, and yet many people are driven by unconscious bias," says Sara Wakeman, M.D., medical director of the substance use disorder initiative at Massachusetts General Hospital.
Wakeman is co-chair of MGH's Opioid Task Force, which has been examining the hospital's prescribing rates and establishing uniform guidelines to minimize opioid use — but also ensure that patients are receiving compassionate care for pain.
"We know that there are disparities in access to addiction treatment based on race and socioeconomic status. So it's important to acknowledge that and the bias that goes into that as we explore this complicated issue," says Wakeman.
Substance use disorder risk assessment surveys are an essential tool in the effort to avoid bias in pain management, she says. Just as all patients get their blood pressure checked, she says, all patients should be screened for addiction risk before they get an opioid prescription.
And it shouldn't matter what those patients look like or what type of insurance they have, Wakeman says.
"This is just a part of good care," she says. "The reality is that opioid addiction, which is what we're trying to prevent, can happen to anyone."