Changes in Opioid Prescribing and Use after Implementation of a State Medicaid Prior Authorization Policy

Patients within state Medicaid programs have been disproportionately impacted by the opioid epidemic. A greater proportion of Medicaid enrollees receive opioids than commercially insured populations, there is a high prevalence of inappropriate prescribing (e.g., overlapping prescriptions, co-prescription of opioids with benzodiazepines), and there is an elevated overdose rate among Medicaid beneficiaries. In an attempt to reduce inappropriate opioid prescribing and improve pain management by encouraging other therapies, Maine’s Medicaid program, called MaineCare, implemented an opioid prior authorization (PA) policy. The policy covers both acute and chronic pain conditions, with specified requirements for each condition. CDC is evaluating MaineCare’s PA policy to determine: 1) if the policy resulted in changes in opioid prescribing and inappropriate use; and 2) if the policy resulted in changes in use of other therapies including non-opioid medications (e.g. NSAIDs, tricyclic antidepressants, and SNRIs) and nonpharmacologic treatments.

Using a comparative interrupted time series design, we conducted a retrospective analysis of all-payer claims data from Maine 2012-2013 comparing Medicaid beneficiaries to Medicare and commercially insured groups. Outcome measures included prescription rate, mean daily dosage (MME) per prescription, proportion of prescriptions < 30 MME, high daily dosage (> 90 MME), nonopioid medications, and nonpharmacologic treatments. Preliminary findings indicate that the number of opioid prescriptions per 1,000 MaineCare members per month decreased 28% after the policy was implemented, and mean daily dosage per opioid prescription reduced by 10% from 60 MME/day to 53 MME/day. MaineCare members with high daily dosage was reduced by 13.5%. Comparable reductions were not evident for Medicare or commercially insured beneficiaries. Presenters discuss findings from additional analyses examining use of nonopioid medications, nonpharmacologic treatments, and changes in health outcomes (e.g., emergency department visits).

Rigorous evaluations using comparative time series designs can assist in identifying policies that can address the opioid overdose epidemic. Prior authorization policies hold promise reducing negative outcomes from the overuse of opioid pain medication. Understanding how such policies improve pain treatment, as well as reduce negative consequences of opioid therapy, will be critical to ensuring such strategies meet the needs of patients and promote health outcomes.