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How States’ Medicaid Policies Expose Poor People to a Deadly Painkiller

Methadone made up just 1 percent of opioid prescriptions in 2014, but was involved in 23 percent of opioid-overdose deaths.
(Photo: fragglerawker/Flickr)

(Photo: fragglerawker/Flickr)

Of all the prescriptions doctors wrote for opioid painkillers in 2014, only 1 percent were for methadone. Yet methadone was involved in 23 percent of fatal prescription painkiller overdoses in America that year.

These striking numbers come from a new report published by the Centers for Disease Control and Prevention (CDC) that tackles a problem that’s long been known by specialists in the field: Among the opioid pain relievers, methadone can be especially dangerous. But because it’s much cheaper than similar medicines, methadone often finds its way to America’s low-income patients, subsidized by Medicaid. That leaves poorer Americans disproportionately likely to overdose on methadone, presumably some of them simply from taking the medicines they were prescribed.

The new CDC study offers a solution: States may be able to write policies in a way that reduces methadone overdose deaths among people covered by Medicaid, which is now the country’s single largest health coverage provider.

The secret to methadone’s deadliness is the timing of its effects on the body. Though the drug is more commonly known as a medicine for people with opioid use disorders—taken as a way to manage their addiction—it also works to relieve pain for four to eight hours, according to the Food and Drug Administration. But the medicine can linger in the body for more than two days, which is dangerous if pain patients are tempted to take another dose once their aches return, but before their bodies have cleared the last dose. Methadone can then build up to toxic levels in their systems, altering their heart rates and slowing or stopping their breathing, all without their noticing. And while folks under the care of a methadone clinic have to come back every day for their dose, pain patients may get several days’ worth of methadone at once.

In 2006, the FDA published a warning to consumers about methadone as a pain reliever. Over 5,400 Americans died with methadone in their systems that year. Of course, some of those deaths may have resulted from illegally obtained methadone, or by mixing methadone with other drugs, but it’s likely at least some were taking their medicines as directed. In 2011, Seattle Times journalists found that up to 80 percent of people in Washington state who died with methadone in their bodies hadn’t also been taking any illicit drugs, such as cocaine, at the time of their deaths.

Some of those pain patients received their methadone thanks to their states’ Medicaid plans, specifically through preferred drug lists—lists that most states publish, saying which drugs they’ll cover for Medicaid patients. Should a doctor want to prescribe an off-list drug to a patient and have it covered, she has to receive additional authorization. States use preferred drug lists to nudge doctors to prescribe cheaper and more effective medicines. As of 2015, most states listed methadone as a preferred drug, despite its dangers, mostly because of its low price, the Pew Charitable Trusts reports. Methadone costs three to four times less than its nearest competitor, the Seattle Times reports, and 12 times less than OxyContin.

The result of that listing has been damaging. In 2014, Americans covered by Medicaid were nearly twice as likely as those with private insurance to be prescribed methadone, the new CDC report finds. And when CDC researchers compared the numbers from three Eastern states, they found that Medicaid patients in Florida and North Carolina, both of which will reimburse for methadone prescriptions, were more likely to overdose on methadone than Medicaid patients in South Carolina, which doesn’t reimburse for methadone.

Things are slowly turning around, the CDC finds. Methadone overdose deaths peaked in 2006, at the time of the FDA warning; between 2006 and 2014, they’ve declined 39 percent. But there’s still plenty of room for improvement. The CDC scientists suggest that, if other research confirms their findings from North Carolina, South Carolina, and Florida, states should consider removing methadone from their preferred drug lists. They also suggest some solutions outside of changing Medicaid policy. States can make sure doctors know they shouldn’t turn to methadone as their first-choice painkiller, for example, and deploy prescription drug monitoring programs, which doctors can log into to see what other prescriptions patients are getting.