By Alison Knopf

Senior citizens are not immune from opioid use disorders (OUDs), but Medicare does not cover treatment in an Opioid Treatment Program (OTP). The American Association for the Treatment of Opioid Dependence (AATOD), Advocates for Opioid Recovery (AOR), and the Collaborative for Effective Prescription Opioid Policies (CEPOP), are trying to change this.

AOR and CEPOP sponsored a briefing at the U.S. Capitol Visitor Center in Washington D.C. on November 15. The meeting focused on increasing access to medication-assisted treatment, specifically with methadone and buprenorphine. While opioid briefings have become almost a daily event on Capitol Hill, this one was special in that it brought out the need for better access to OTPs.

The problem:

• Seniors commonly take opioids for pain management; in 2016, one out of every three Medicare beneficiaries received at least one prescription opioid through Part D, Medicare’s insurance coverage for pharmaceuticals
• Prescription opioids have a high risk for misuse or abuse
• Symptoms of prescription opioid misuse or abuse may be hard to recognize in older adults, because they resemble some symptoms that may accompany aging, such as memory changes
• Methadone is covered by Part D only when prescribed for pain, not for treating OUD, because in Part D it cannot be dispensed by prescription at a retail pharmacy
• Methadone cannot be covered by Medicare Part D because it is administered through outpatient OTPs

The solution:

Congress should immediately authorize Medicare coverage of all medications approved for treating OUDs–methadone, buprenorphine, and extended-release naltrexone. Currently, only in OTPs can methadone be dispensed to treat OUDs.

DC Briefing

At the November 15 briefing, Angela Caldwell, MS, lead counselor and program coordinator at Montgomery Recovery Services, an OTP in Rockville, Maryland, described a case of an older patient whose insurance coverage was terminated when she became eligible for Medicare at the age of 65.

The solution wasn’t perfect. The program found a physician willing to continue treating her with methadone, but as a pain patient. However, the ways methadone is prescribed for chronic pain and for addiction are very different. For pain, dosing is by pill and split throughout a 24-hour period. For addiction, patients need to take only one liquid dose every 24 hours.

The patient under discussion had been maintained on 70 milligrams; the physician lowered her dose to 40 milligrams. “It wasn’t ideal, but it was the best we had to work with,” said Ms. Caldwell. “We need to treat this as a disorder.”

Ms. Caldwell went on to read a letter from a 66-year-old patient in the program, who has stayed off heroin for 23 years, thanks to the OTP. He attends group sessions at Montgomery Recovery Services, where he can share his fears. (He has severe depression and anxiety attacks.)

“My depression is multiplied tenfold since, when I turned 65, I was told I might not be able to continue my treatment,” he wrote. “I don’t want to guess what might happen to me.”

With Coverage, Services Increase

Mark Parrino, MPA, AATOD president, has been working with Congressional committees on Medicare Part B coverage. He said at the November 15 briefing that the increased access to treatment resulting from the expansion of Medicaid, and from the decision by states to allow Medicaid to cover treatment in an OTP, have made a huge difference in the opioid epidemic. He explained that when states add Medicaid reimbursement, the use of OTP services increases by 20%.

In states where Medicaid does not pay for OTPs, 85% of the patients make out-of-pocket payments, said Mr. Parrino. “If they can’t do that, they can’t get into treatment.” He added that in states that have robust Medicaid-OTP programs, like New York, California, and Pennsylvania, 85% to 90% of patients in OTPs are covered by Medicaid.

“This is not a criticism of treatment centers that do not use medications to treat opioid use disorders,” said Mr. Parrino. “But there are only 1,500 OTPs in this country. That is not a profound number, and it’s woefully inadequate to meet the increasing demand for services.”

Because of the addiction epidemic, some of the bias against OTPs is evaporating, said Mr. Parrino. “People are starting to say, ‘We need treatment in our community.’”

Medical Experts and Former Legislators Call for Coverage

Mary Bono, former representative from California, and founder of CEPOP, stressed that treatment with buprenorphine or methadone reduces the risk of death. “I’ve had employees who are in methadone treatment,” she said. “Congress has to get this done,” she said of Medicare coverage of methadone.

Patrick J. Kennedy, former representative from Rhode Island, and an outspoken proponent of treatment, called for funding. “We have great recommendations, but where is the money to implement them?” he asked. “Either this is a national emergency, or it isn’t.”

Frances Levin, MD, past president of the American Academy of Addiction Psychiatry, noted that the presence of fentanyl in almost all drugs sold on the street as opioids has drastically changed the situation for people who need treatment. “We are testing all patients, and most are coming up positive for fentanyl,” said Dr. Levin, who is also Kennedy-Leavy Professor of Clinical Psychiatry at Columbia University, and Chief of the Division on Substance Abuse at New York Presbyterian Hospital. “They didn’t even know they had taken it,” Dr. Levin said, referring to fentanyl.

She added that even patients who are tolerant to opioids can still overdose on fentanyl. “It’s 50 times stronger than morphine,” she said. “Clinicians are finding that even two naloxone kits aren’t necessarily enough” to reverse a fentanyl overdose.

The funding needed to reverse the opioid epidemic—$15 billion a year, according to Mr. Kennedy—isn’t likely to materialize any time soon, said Ms. Bono. “There isn’t going to be enough funding, so we have to spend our money wisely. Medicare coverage for methadone is a no-brainer.”

Mr. Parrino recommends that Medicare Part B cover federally approved medications utilized in an OTP in addition to all the comprehensive services, which are offered through OTPs.

The briefing, which was streamed on Facebook, was moderated by Brianna Ehley of Politico.

A fact sheet from the briefing is available at: http://www.atforum.com/pdf/AOR-HILL-BRIEF-FACT-SHEET-FINAL.pdf