Methadone Death Toll Varies By Medicaid Preferred Drug List Policies

As the opioid epidemic continues to claim lives across America, a new study finds that methadone overdoses, although declining, result in a disproportionate amount of deaths. CDC finds that adjustments to drug reimbursement policies, including the lists of preferred medications used in Medicaid programs, could help states bring their number of methadone-related deaths even lower.

In an attempt to identify drivers of methadone overdoses, researchers looked to Medicaid coverage as a source of disparity and investigated the potential association between a state’s drug reimbursement policies and methadone overdose rates. Their results were published in the Morbidity and Mortality Weekly Report.

Methadone is an opioid prescribed to treat chronic pain and, more rarely, to help manage opioid addiction. Although it accounts for just 1% of all opioid prescriptions in the United States, it was responsible for 22.9% of all opioid-related deaths in 2014, according to the most recent available data. Methadone's overdose death rate increased 600% from 1999 to 2006, then decreased to its current rate of 1.1 per 100,000 people in 2014. The number of methadone deaths is almost equal to the 1999 death rate from all prescription opioid overdoses, which has since quadrupled to 4.6 per 100,000.

The study authors determined that the methadone prescribing rate among Medicaid enrollees was nearly double that of enrollees in private plans who were represented in a large commercial database. In an effort to identify policies that may play a role in methadone overdose rates among Medicaid beneficiaries, the researchers compared outcomes within 3 states that differed by methadone’s status as a preferred drug in their Medicaid reimbursement policies.

During the study period of 2012 to 2013, methadone was on Florida’s preferred drug list for CMS and was considered preferred in North Carolina although not included on the list,. It was not a preferred drug in South Carolina. A medication’s status as a preferred drug ensures prescribers do not have to obtain prior authorization for the patient’s claim to be paid, meaning that “prescribing drugs from the preferred list makes the approval process less cumbersome and facilitates faster reimbursement.”

Death rates for overall opioid overdoses were similar across the 3 states, which were chosen for the study in hopes that their geographic closeness would result in comparable populations. Consistent with their hypotheses, the researchers found that the rate of fatal and nonfatal methadone overdose among Medicaid beneficiaries in South Carolina, where it was not a preferred drug, was significantly lower than the rates in both North Carolina and Florida.

These results indicating a link between preferred drug policies and methadone overdose rates could encourage states to adopt Medicaid drug utilization management strategies to reduce the incidence of overdoses. Removing methadone from the state’s preferred drug list could serve as one approach in the toolbox, along with policies like prior authorization requirements, quantity limits, retrospective review, prescribing guidelines, and prescription drug monitoring programs.

The researchers acknowledged that South Carolina’s lowered incidence of methadone overdoses could also be a result of other efforts, “such as requiring pain management providers to be certified and a process to identify prescribers not authorized to prescribe controlled drugs,” that worked in conjunction with the preferred drug list policies.

Still, the authors wrote, the severity of the opioid epidemic requires a multifaceted approach that uses a number of successful evidence-based strategies, including the rewriting of preferred drug lists.

“Amid a growing epidemic of deaths with widespread overuse of prescription opioids, understanding the successful strategies for the reduction in methadone overdose are important and might serve as a model for future positive outcomes involving other opioid drugs,” they concluded.