MMWR: Methadone Prescribing and Overdose and the Association with Medicaid Preferred Drug List Policies — United States, 2007–2014
MMWR: Weekly / March 31, 2017 / 66(12);320–323
From the Discussion section
Drug overdose deaths involving methadone peaked in 2006 and 2007, then declined 39% by 2014. Despite this decline, however, methadone continues to account for nearly one in four prescription opioid-related deaths. Although this study was not designed to assess causal inference, the peak inflection point in 2007 occurred shortly after the December 2006 issuance of the Food and Drug Administration’s Public Health Advisory on prescribing methadone that linked reports of respiratory depression and cardiac arrhythmias with the possibility of unintentional overdoses, drug interactions, or cardiac toxicity (4). The voluntary manufacturer restriction limiting the 40 mg formulation of methadone in 2008 likely also contributed to declines in methadone overdose death rates (8).
Given that methadone prescribing rates are higher among persons enrolled in Medicaid, strategies to reduce methadone prescribing among persons in this population might further reduce injuries and deaths from methadone. Focusing on the differences between state PDLs, a comparative exploratory analysis of states with different methadone drug utilization management policies found an association between a state’s internal PDL policy and methadone overdose rates. If confirmed by additional studies, other states could consider Medicaid drug utilization management strategies such as PDL placement among other evidence-based strategies to reduce injuries and deaths associated with methadone.§ Other pharmacy management strategies (e.g., prior authorization, quantity limits, and retrospective drug utilization review), as well as adherence to clinical prescribing guidelines and the increased deployment of prescription drug monitoring programs, might also help to optimize the benefit of methadone. Many of these approaches might also be applicable to private insurers.
The findings in this report are subject to at least two limitations. First, the analysis of mortality and morbidity data included all methadone overdoses. Because methadone is prescribed for pain and also to treat opioid use disorders in community-based opioid treatment programs, there is no definitive way to determine the source of methadone contributing to an injury or death. However, because methadone prescribed to treat opioid use disorders is tightly regulated (including an extra set of special standards) (9), the preponderance of methadone-associated morbidity and mortality likely arises from its use for pain. Second, findings from the policy analysis of PDL and overdose rates are exploratory in nature, and there are many potential determinants of methadone-related overdose rates beyond PDL policies. For example, South Carolina reported in its fiscal year 2013 Medicaid Drug Utilization Annual Report that it had implemented other drug utilization management strategies, such as requiring pain management providers to be certified and a process to identify prescribers not authorized to prescribe controlled drugs, whereas North Carolina and Florida did not have these policies at that time.
Amid a growing epidemic of deaths with widespread overuse of prescription opioids, understanding the successful strategies for the reduction in methadone overdose are important and might serve as a model for future positive outcomes involving other opioid drugs. Options for reducing future opioid morbidity and mortality include implementing multiple drug utilization management policies that are consistent with PDL practices and the CDC Guideline for Prescribing Opioids for Chronic Pain (10), which recommends that methadone should not be the first choice for an extended-release/long acting opioid.