Few Medicare Enrollees Receive Meds for Opioid Use Disorder

In the United States, 2.1 million people suffer from opioid use disorder, which is the chronic overuse of opioids leading to significant distress or impairment, per the National Library of Medicine. The opioid epidemic claimed 83,827 lives in the United States in 2022.

While substance abuse has been escalating among older Americans, it’s an issue that has largely fallen under the radar. Yet, as chronic conditions increase and worsen with age, opioid use disorder disproportionately affects older adults because treatment for chronic pain can involve potentially addictive medications. According to the National Institute on Drug Abuse, pain affects as many as 80 percent of older cancer patients and 77 percent of seniors with heart disease. Forty percent of outpatients 65 and older report pain.

As opioid misuse affects older adults and people with disabilities, Medicare covers treatment for opioid use disorder. Opioid use disorder impacts 1.1 million Medicare recipients, and in 2022, 52,000 Medicare enrollees experienced an opioid overdose, a recent report from the United States Department of Health and Human Services (DHHS) reveals. The DHHS suggests that the accurate number of overdoses were likely higher because recipients could have received care not billed to Medicare.

What Medicare Covers

Medicare supports services and prescription medications to treat opioid use disorder.

• Part B covers services in opioid treatment programs. Treatment programs enrolled in Medicare provide care without a copayment, but copayments may apply for supplies and medications.
• Part D covers prescription drugs, including buprenorphine and methadone.
• When an enrollee receives treatment in a hospital, Part A covers methadone.

Services Medicare covers also include substance use counseling, individual and group therapy, and periodic assessments in person and online. The program also pays for drug testing and overdose education.

Lack of Access to Medication

While Medicare covers prescription medications for opioid use, few enrollees receive them. The DHHS report found that only 18 percent of Medicare enrollees struggling with opioid dependence received medication such as naloxone, buprenorphine, and methadone.

In some states, the percentage of people receiving medication was lower. In Florida, Texas, Kansas, and Nevada, fewer than 10 percent received medication to treat their opioid use disorder. Florida – the state with the highest number of enrollees suffering from opioid abuse – had the lowest rate of 6 percent.

Older adults also received less medication compared to younger Medicare recipients. Only 11 percent of older people struggling with opioid dependence received medication in 2022, compared to 29 percent of recipients under 65 who qualified based on disability.

This treatment disparity contrasts with the prevalence of opioid use disorder among older adults. Enrollees who qualified because of age account for 60 percent of the cases of opioid use disorder.

Changes in Naloxone Access

When an opioid overdose causes breathing to stop, the generic drug naloxone and its brand name equivalent, Narcan, work by restoring breathing, preventing suffocation.

Although the percentage of Medicare recipients who got medication for treatment for opioid use disorder was low, the number who used the overdose reversal medicine naloxone reached a record high. Upwards of 600,000 individuals on Medicare got naloxone through Part D in 2022. This marked a 36 percent increase from 2021.

In September 2023, Narcan became available over-the-counter (OTC), resulting in generic brands also becoming OTC. The change to OTC could improve access for some people, as they do not have to go through providers to obtain the overdose reversal drug.

However, this also poses a problem for Medicare recipients. Because Part D only covers prescription drugs, it will no longer cover naloxone. For some, the price of the drug may be cost-prohibitive. Narcan’s suggested over-the-counter price is $44.99.

Other options for Medicare enrollees to receive the life-saving drug include the following:

• Some Medicare Advantage Plans cover OTC naloxone.
• Depending on the state, dual enrollees in Medicare and Medicaid may get coverage through Medicaid.
• Recently approved by the Food and Drug Administration, nalmefene nasal spray is a prescription drug that Part D covers. Similar to naloxone, this medication stops an overdose.

Seeking Professional Help

If you or an older loved one struggles with opioid use disorder, be sure to support them in getting the help they need. The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a free and confidential national helpline at 1-800-662-HELP. You can call this hotline any time of day, any day of the week to receive treatment referrals and other information in both English and Spanish.

In addition, an attorney can help you determine what treatment options Medicare may cover for your loved one. They may also be able to assist with obtaining covered treatment services. Find a qualified elder law attorney near you for guidance.

Access the full report in PDF format for further insights.