Analysis of insurance coverage for back pain shows missed opportunities to prescribe non-opioid medications

Science Spotlight

ale Doctor and patient suffering from back pain during medical exam
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A comprehensive analysis of health insurance coverage of non-opioid and opioid medications to treat chronic low back pain concluded that some insurance plans have missed important opportunities to steer patients towards safer and more effective treatments than prescription opioids. These results underscore that while most plans recognize the importance of strategies related to the opioid overdose crisis, there is a need for insurers to encourage the utilization of safe, effective alternatives to prescription opioids. The analysis was published today in JAMA Network Open.

In a cross-sectional study of 2017 health insurance plans, researchers focused on 62 medications to treat low back pain, one of the most common causes of chronic pain in which prescription opioids have been overused. The authors analyzed health insurance plans of 15 Medicaid, 15 Medicare Advantage and 20 commercial insurers comprising 16 states representing more than half the U.S. population, all of which are affected by the opioid overdose epidemic. Additionally, the researchers conducted 20 interviews with 43 senior medical and pharmacy health plan executives of the represented plans. The data analysis was conducted from April 2017 to January 2018.

The study discussed the importance of utilization management, including: quantity limits (limits on the number of pills per prescription); step therapy (requiring that treatment start with a non-opioid medication, such as an over-the-counter anti-inflammatory first before an opioid is prescribed or starting with a specific opioids before other opioids are authorized); and prior authorization (prescriber to contact the insurer for pre-approval before writing a prescription that the insurer will cover). The analysis showed that, in all plans, the quantity limits commonly used for opioids included a 30-day supply, rather than a shorter supply as recommended in the most recent CDC Guideline for Prescribing Opioids for Chronic Pain. Step therapy was rarely used for covered opioids (9 percent for Medicaid; 4 percent for commercial plans; virtually none for Medicare); and the restrictiveness of prior authorization varied among the plans, some requiring a medical rationale for the continuation of opioids while others only required a diagnosis of chronic pain.

The analysis was funded by the National Institute on Drug Abuse (NIDA), the U.S. Department of Health and Human Services (DHHS), and the Centers for Disease Control and Prevention. NIDA is part of the National Institutes of Health, within DHHS.

For a copy of the paper, published in the JAMA Network Open, go to Prescription Drug Coverage for Treatment of Low Back Pain Among US Medicaid, Medicare Advantage, and Commercial Insurers

For more information about prescription, opioids and pain, go to: Prescription Medicines, Opioids, and Pain.

For more information, contact the NIDA press office at or 301-443-6245. Follow NIDA on Twitter and Facebook.

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About the National Institute on Drug Abuse (NIDA): NIDA is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world’s research on the health aspects of drug use and addiction. The Institute carries out a large variety of programs to inform policy, improve practice, and advance addiction science. For more information about NIDA and its programs, visit

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