Facing an opioid overdose epidemic showing no signs of slowing, states have resorted to a variety of measures to improve opioid prescribing practices and reduce the risk of individuals developing opioid use disorders (OUD). While there are currently no enforceable limits on the amount of opioids a provider can prescribe in California (as in some other states), the state and individual entities have undertaken other efforts that may curb inappropriate prescribing without endangering the right of Medi-Cal beneficiaries to receive medically necessary services.
First, in 2014, the Medical Board of California updated its Guidelines for Prescribing Controlled Substances for Pain. These guidelines recommend that opioids for treatment of acute pain be prescribed for a short duration and only when other non-opioid therapies would not provide adequate relief. For both acute and chronic pain, the guidelines recommend that physicians proceed with caution once the morphine equivalent dose (MED) of a prescription reaches 80 mg/day. Once that level is reached, prescribers are recommended to take additional preventive steps, including monitoring opioid use through CURES, California’s Prescription Drug Monitoring Program, and referring the patient to an appropriate specialist. While these guidelines are not legally binding, it is likely that California physicians are increasingly adhering to the recommendations on a voluntary basis in response to the opioid epidemic.
Second, in October 2017, Governor Brown signed into law AB 1048, authorizing pharmacists to dispense opioid prescriptions as a partial fill if requested by the patient or the prescriber. The law was enacted in response to the federal Comprehensive Addiction and Recovery Act (CARA), which permitted partial fills for a Schedule II controlled substance if not prohibited by state law. Under both CARA and AB 1048, the remaining portion of a partially filled prescription may be filled no later than 30 days after the date of the prescription. AB 1048, which goes into effect in June 2018, will provide providers with an additional tool to ensure that patients are being dispensed only the necessary dose of opioid medications.
Third, California has recently expanded Medi-Cal coverage of non-opioid alternatives for pain relief. SB 833, signed into law in June 2016, which restored acupuncture services as a covered benefit under the Medi-Cal program. Providers now have the option of referring beneficiaries for acupuncture services before prescribing opioids for pain treatment. Similarly, providers may increasingly resort to alternative, Medi-Cal covered services, such as physical therapy, or to other non-opioid medications available over-the-counter.
Finally, Medi-Cal managed care plans (MCPs) may also play a role in promoting safer prescribing practices. For instance, Partnership Health Plan are covering acupuncture services as an alternative to opioid treatment before passage of SB 833. Similarly, MCPs may expand coverage of other non-opioid therapies for pain that are not mandated by Medi-Cal, including the full scope of chiropractic services. Moreover, in an effort to reduce long-term opioid dependence and following the CDC Guidelines for Opioid Prescribing, some MCPs are requiring a Treatment Authorization Request (TAR) for an opioid prescription exceeding 7 days.
Of course, Medi-Cal is still required to pay for all medically necessary medications covered under California’s state plan. While nothing precludes providers from refusing to prescribe an opioid medication, beneficiaries who believe they were improperly denied Medi-Cal coverage of medically necessary opioids should appeal the decision with their health plan or Medi-Cal. Nonetheless, in the midst of an unprecedented opioid overdose epidemic, the efforts outlined above represent a positive step forward in the state’s fight to reduce the burden of OUDs in California while upholding the rights of Medi-Cal beneficiaries in need of medically necessary medications.