Health Insurance Pharmaceuticals

Prior authorization and opioid abuse

An interesting article by Cochran et al. (2017) examines whether health plan prior authorization rules can help prevent opioid abuse.  The authors use Pennsylvania Medicaid data from 2010 to 2012.  The data included both fee-for-service and managed care enrollees.

The authors measured opioid abuse based on diagnosis codes for opioid use disorder (304.0, 304.00, 304.01, 304.02, 304.03, 304.7, 304.70, 304.71, 304.72, 304.73, 305.5, 305.50, 305.51, 305.52, 305.53) or opioid medication poisoning (965.00 [opium poisoning], 965.02 [methadone poisoning], 965.09 [opiate poisoning—not elsewhere classified], E.850.1 [accidental methadone poisoning], and E.850.2 [accidental opioid poisoning—not elsewhere classified]).  They also required the patient to have overlapping fills for pain medication.

The authors estimated the prior authorization stringency based on the number of opioids that required prior authorization.  They found that:

…a minority of plans implemented PA [prior authorizatoin] policies (3 of 9 plans) and there was substantial variation in the number of medications within plans subjected to PA policies (range = 1-74).  Enrollment in High and Low PA plans was associated with modestly lower adjusted rates of opioid medication abuse, and enrollment in the Low PA plan was associated with lower adjusted rates of overdose. These results are consistent with those of previously published studies that have examined the effects of PA on opioid medication fills. Specifically, our findings that PA was associated with 7% to 11% (P <.05) lower rates of abuse and 12% (P = .08) to 25% (P = .02) lower rates of overdose are consistent with studies that have reported 8% to 19% reductions in long-acting opioid medication fills among enrollees in plans that utilized PA policies.

So, does that mean that prior authorizations are a good thing?  On the one hand, prior authorizations seem to reduce abuse.  In fact, the authors conclusions may be conservative since the analysis focuses on individuals who start opioids.  Prior authorization may provide a barrier to initiating a patient on opioids in the first place.

However, opioids also have benefits in terms of pain reduction.  Prior authorizations likely decrease access to opioids among patients who could benefit from these treatments.

Clearly, policies such as prior authorizations that would restrict opioid use must weight the benefits in terms of decreased patient abuse with the harms in terms of decreased access to pain medication among those who need it.  This study only looks at the former, but policy decisions should be made weighing both components.  Nevertheless, this is an interesting study on how prior authorization can restrict drug access and–in this case–potentially reduce opioid abuse.


Gerald Cochran, PhD; Adam J. Gordon, MD, MPH; Walid F. Gellad, MD, MPH; Chung-Chou H. Chang, PhD; Wei-Hsuan Lo-Ciganic, PhD, MS, MSPharm; Carroline Lobo, MS; Evan Cole, PhD; Winfred Frazier, MD; Ping Zheng, MD, MS; David Kelley, MD; and Julie M. Donohue, PhD. Medicaid Prior Authorization and Opioid Medication Abuse and OverdoseAmerican Journal of Managed Care. Published Online: May 26, 2017.

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