Every day, 130 Americans die from an opioid overdose. Tragically, these deaths are entirely preventable; like other substance use disorders (SUDs), opioid use disorder (OUD) is a preventable and treatable disease. There are currently three medications approved by the Food and Drug Administration (FDA) for OUD treatment: methadone, buprenorphine, and naltrexone. Despite research demonstrating their efficacy, particularly for methadone and buprenorphine, fewer than half of patients with OUD receive these medications.
The Center on Addiction monitors SUD benefits in commercial health insurance plans and evaluates the Affordable Care Act’s (ACA’s) impact on insurance coverage for evidence-based SUD care. We closely evaluate the benefits offered by plans required by the ACA to cover SUD treatment as an essential health benefit (EHB). Our research demonstrates that, in most states, plans subject to this requirement do not provide comprehensive coverage for SUD benefits. Of particular concern, methadone, the gold standard in OUD treatment, is frequently excluded by commercial insurers. While plans are not required by the ACA to cover methadone, recently, the federal government clarified that excluding coverage of methadone for OUD may violate federal laws, including the ACA’s nondiscrimination provision and the Mental Health Parity and Addiction Equity Act of 2008 (the Parity Act). While these clarifications are important, our research findings demonstrate the need for the federal government to take stronger action to prohibit discriminatory practices and improve coverage for methadone treatment for OUD.
Barriers To Medications For Opioid Addiction
Opioid use disorder medications are underused for a number of reasons. The medications are inaccessible to many patients because few treatment facilities or health care providers offer them. Stigma, rooted in an erroneous belief that these medications “substitute one addiction for another,” often discourages providers from offering, and patients from taking, these medications. Insurance coverage barriers and cost make treatment, including these medications, unaffordable to many patients with OUD.
Addressing each of these barriers will require a number of different strategies and policy interventions. The federal government must closely examine the federal laws that restrict the types of treatment facilities that can offer methadone and types of providers that can prescribe buprenorphine to better balance availability of these medications with concerns about diversion and misuse. States, which are responsible for licensing and credentialing, should require addiction treatment providers and facilities to use evidence-based practices. Increased SUD training for health care providers is needed in medical schools and continuing medical education. The public needs to be better educated on addiction and its treatment. Federal and state insurance regulators need to better enforce laws meant to improve insurance coverage and reduce discriminatory insurance practices to make treatment more accessible and affordable.
The FDA approved methadone for treatment of pain and OUD. When prescribed for pain management, methadone is covered on the plan’s formulary, under the prescription drug benefit, and dispensed in a pharmacy like any other type of controlled substance. When used for OUD treatment, methadone coverage appears in the plan’s evidence of coverage, under the medical benefit, because it is subject to unique federal dispensing requirements and can only be dispensed by specially licensed opioid treatment programs.