Health Insurance and its Influence on the Opioid Epidemic

Greed is keeping Americans sick. More on what the health insurance industry is doing in the face of the Opioid Epidemic … and possible solutions that can turn the tide.

minute read

No Easy Answers

The United States continues to struggle with solutions to combat the opioid epidemic. Some policy makers believe limiting opioid prescriptions is the answer, while others believe this type of legislation will result in more addicts turning to street drugs. There are no easy answers to get this epidemic under control, but one thing is certain.

The health insurance industry is not helping the situation by limiting coverage on opioid prescriptions and refusing to cover alternative non-opioid treatment.

More here on the Opioid Epidemic and systems that can both help and harm the people. Then, we invite your questions or feedback in the comments section at the end. REMEMBER: We try to respond to all comments with a personal and prompt reply!

Profit and Greed

The most obvious contributors to America’s opioid epidemic are profit and greed. All entities, from Big Pharma to the Health Insurance Industry, are in business to make money. Physicians who face criminal charges for improper prescribing are typically doing it for personal financial gain rather than the well-being of their patients. Drug traffickers are making more profit than ever with their increased sales of heroin and fentanyl as a result of this epidemic.

In order to get this epidemic under control, all legitimate entities must put their efforts on a solution rather than profit.

Opioid Rx Guidelines

The CDC (Centers for Disease Control and Prevention) published their Opioid Prescribing Guidelines last year which recommends that physicians avoid increasing dosages of opioids greater than 90 MME (Morphine Milligram Equivalents). CMS (Centers for Medicare and Medicaid Services) are considering adopting this as permanent policy and blocking all opioid prescriptions that exceed this threshold.

Direct Problems with Insurance Coverage

Some insurance carriers have already implemented policy to decline coverage for any medicines prescribed above the CDC threshold. However, this poses challenges for both the physician and patient, particularly those chronic pain patients who have been on opioids for years and have developed a high level of tolerance.

Furthermore, insurance companies are not systematically reimbursing non-opioid alternatives. Physicians attempting to relieve their patients’ pain without opioids are having difficulty with insurers covering alternative treatments. One example of alternative treatment is epidural injections. CMS has reduced reimbursement for these procedures from 56% to 19%, thus making it unaffordable for most patients.

Other options with low reimbursement rates include:

  • steroid injections
  • joint injections
  • fluid injections
  • physical therapy
  • nerve blocks
  • radio-frequency ablation

All of these are other, alternative treatments advocated by pain specialists in place of opioids. However, most insurers will not cover these procedures. Insurers refuse to cover these procedures simply because they cost more. An opioid prescription is cheap, quick and easy.

Do The Insurers Really Care About Diversion Of Pharmaceuticals To The Black Market?

It seems not.

I was in Toledo, Ohio earlier this year training physicians on how to remain compliant with the DEA in their respective practices. Ohio has one of the highest drug overdose death rates in the nation and the state has a severe problem with the abuse and diversion of opioids. One treatment provider advised that their facility prefers to treat addiction with Suboxone film (administered sublingually) because it is easier to monitor and less likely to be diverted to the black market.

However, the insurers will only provide reimbursement for the generic Suboxone tablets which in turn, leads to more abuse and diversion. The treatment provider pleaded with the insurance representative explaining the problem with diversion, but the insurer did not budge.

If a clinic pleads with the insurance company to cover Suboxone film to combat diversion, why are they reluctant to comply?

Is it simply because the generic tablets are cheaper?

Decisions made by insurance companies are usually about their bottom-line unless there are laws that mandate coverage of specific services.

Another example of the health insurance industry’s lack of concern to combat the opioid epidemic is that most insurers fail to provide coverage for TR/ADFs (Tamper-resistant/abuse-deterrent formulations) opioid medications, even when physicians recommend them for patients. These types of medications were developed to combat abuse of opioids.

One example of a tamper-resistant medication is a pill made with a special polymer coating that makes it difficult to crush, break, or dissolve. The tamper-resistant pill also turns into gel if mixed with liquid so it cannot be injected. These formulations make the medication less likely to be abused and diverted to the black market. However, the majority of insurers opt to cover traditional generic non-TR/ADFs, the cheaper versions that are more subject to abuse and diversion.

Where Does That Leave Us?

The CDC guidelines recommend that physicians utilize alternatives to opioid therapy; however, the insurers are denying coverage. Physicians who are attempting to reduce opioid therapy are sometimes left with no other option than to prescribe opioids because the majority of patients cannot afford to pay for alternative therapy. Physicians often feel pressured to taper the patient off of opioids which often causes patients to self-medicate with heroin. This cycle of abuse will continue unless changes are made with healthcare coverage.

What Is The Solution To Expand Health Insurance Industry Coverage?

One solution would be an attempt to change the law of what insurers must cover. Pain Physician’s Associations such as the American Society Of Interventional Pain Physicians, Association Of Interventional Pain Physicians, and American Academy of Pain Medicine should contact their respective Senators or State Representatives and request they sponsor a bill to increase specific coverage related to alternative medicine to treat chronic pain. New legislation should also provide coverage to utilize the safest form (TR/ADFs) of medication if a physician requests it. The bill should be drafted with an explanation of how alternative medicine will help patients get off opioids and help to combat the opioid epidemic.

According to the National Conference of State Legislators, every state has a substantial number of laws that require private market health insurance to cover specific benefits and provider services. In addition changing state law, the Physician’s Associations should also persuade legislators to push for implementing mandatory expanded coverage at the Federal level for Medicare, Medicaid and the revised Affordable Care Act.

A Call to Action

As a former DEA agent, I realize that law enforcement alone will not resolve the opioid epidemic. This crisis has to be addressed from all sides and one aspect that is often overlooked is what healthcare insurers cover relative to combating this epidemic. I believe all interested entities should take whatever steps are necessary to get this crisis under control, even if it means sacrificing corporate financial profit.

About the author: Practitioners who desire to have their practice audited for DEA compliance relative to prescribing controlled substances, or if you would like to receive training on the diversion of pharmaceutically controlled substances from retired DEA Special Agent Drug Diversion Expert Warren Rivera, please visit or
Reference Sources: State News: Strict limits on opioid prescribing risk the ‘inhumane treatment’ of pain patients
Business Insider: Pain doctors: Insurance companies won’t cover the alternatives to opioids
Pain News Network: Medicare Planning to Adopt CDC Opioid Guidelines
NIH: The health insurance industry: perpetuating the opioid crisis through policies of cost-containment and profitability
NCSL: State Insurance Mandates and the ACA Essential Benefits Provisions
About the author
Warren Rivera is a retired Assistant Special Agent in Charge from the U.S. Drug Enforcement Administration. Mr. Rivera is an experienced public speaker, trainer and an expert in the diversion of pharmaceutical controlled substances. Mr. Rivera currently owns Training Idea, LLC, a private consulting firm that provides training on DEA matters to the healthcare industry, law enforcement and the community.
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