September 18, 2017
Marilyn Tavenner
President and CEO
America’s Health Insurance Plans
601 Pennsylvania Avenue, NW
Washington, DC 20004
Re: Prescription Opioid Epidemic
Dear Ms. Tavenner,
The undersigned State Attorneys General are sending you this letter to
urge America’s Health Insurance Plans (AHIP) to take proactive steps to
encourage your members to review their payment and coverage policies and
revise them, as necessary and appropriate, to encourage healthcare providers
to prioritize non-opioid pain management options over opioid prescriptions for
the treatment of chronic, non-cancer pain. We have witnessed firsthand the
devastation that the opioid epidemic has wrought on our States in terms of
lives lost and the costs it has imposed on our healthcare system and the
broader economy. As the chief legal officers of our States, we are committed
to using all tools at our disposal to combat this epidemic and to protect
patients suffering from chronic pain or addiction, who are among the most
vulnerable consumers in our society.
The opioid epidemic is the preeminent public health crisis of our time.
Statistics from the Surgeon General of the United States indicate that as many
as 2 million Americans are currently addicted to or otherwise dependent upon
prescription opioids.1 Millions more are at risk of developing a dependency—
1850 M Street, NW in 2014, as many as 10 million people reported using opioids for nonmedical
Twelfth Floor reasons.2 The economic toll of the epidemic is tremendous, costing the U.S.
Washington, DC 20036 economy an estimated $78.5 billion annually.3 State and local governments
Phone: (202) 326-6000 alone spend nearly 8 billion dollars a year on criminal justice costs related to
http://www.naag.org/
1
Surgeon General of the United States, Opioids, https://www.surgeongeneral.gov/priorities/opioids/index.html (last
updated June 1, 2017); Nora D. Volkow, M.D., America’s Addiction to Opioids: Heroin and Prescription Drug Abuse,
National Institute on Drug Abuse (May 14, 2014), https://www.drugabuse.gov/about-nida/legislative-
activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse.
2
See Surgeon General, supra fn. 1 (citing National Survey on Drug Use and Health, Substance Abuse and Mental
Health Services Administration, 2014).
3
Healthday News, Opioid Epidemic Costs U.S. $78.5 Billion Annually: CDC (Sept. 21, 2016),
http://www.health.com/healthday/opioid-epidemic-costs-us-785-billion-annually-cdc.
opioid abuse.4 The human cost is even more staggering: Opioid overdoses kill 91 Americans
every single day.5 More than half of those deaths involve prescription opioids.6
The unnecessary over-prescription of opioid painkillers is a significant factor contributing
to the problem. Although the amount of pain reported by Americans has remained steady since
1999, prescriptions for opioid painkillers have nearly quadrupled over the same timeframe. 7 This
four-fold increase in prescriptions has contributed to a commensurate increase in the number of
opioid overdose deaths.8 The dramatic increase in supply has also made it relatively easy to
obtain prescription opioids without having to resort to the black market: Over 50% of people
who misuse opioids report that they obtained them for free from a friend or relative, while
another 22% misused drugs that they obtained directly from a doctor.9 While illegal opioids like
heroin remain a serious problem that also must be addressed, the role played by prescription
opioids cannot be ignored. While there is no panacea, any comprehensive effort to address and
end the opioid epidemic must tackle the ever-increasing number of prescriptions for opioid
painkillers.
Reducing the frequency with which opioids are prescribed will not leave patients without
effective pain management options. While there are certainly situations where opioids represent
the appropriate pain remedy, there are many other circumstances in which opioids are prescribed
despite evidence suggesting they are ineffective and even dangerous. For example, the American
Academy of Neurology has explained that while the use of opioid painkillers can provide
“significant short-term pain relief,” there is “no substantial evidence for maintenance of pain
relief or improved function over long periods of time.” 10 Another recent study concluded that the
use of opioids to treat chronic, non-cancer related pain lasting longer than three months is
“ineffective and can be life-threatening.”11 When patients seek treatment for any of the myriad
conditions that cause chronic pain, doctors should be encouraged to explore and prescribe
effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to
physical therapy, acupuncture, massage, and chiropractic care.
4
Id. See also Costs of US Prescription Opioid Epidemic Estimated at $78.5 Billion, Wolters Kluwer (Sept. 14,
2016),http://wolterskluwer.com/company/newsroom/news/2016/09/costs-of-us-prescription-opioid-epidemic-
estimated-at-usd78.5-billion.html
5
Understanding the Epidemic: Drug overdose deaths in the United States continue to increase in 2015, Centers for
Disease Control and Prevention, https://www.cdc.gov/drugoverdose/epidemic/ (last updated Dec. 16, 2016).
6
Prescription Opioid Overdose Data, Centers for Disease Control and Prevention,
https://www.cdc.gov/drugoverdose/data/overdose.html (last updated Dec. 16, 2016).
7
See Surgeon General, supra fn. 1; Opioid Addiction 2016 Facts and Figures, American Society of Addiction
Medicine (2016), https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf.
8
Vivek Murthy, The Opioid Crisis: Our Solution, TIME (Oct. 13, 2016), http://time.com/4521562/2016-election-
opioid-epidemic/
9
Opioids, Substance Abuse and Mental Services Administration, https://www.samhsa.gov/atod/opioids (last updated
Feb. 23, 2016).
10
Gary M. Franklin, MD, MPH, Opioids for chronic noncancer pain: A position paper of American Academy of
Neurology, 83 Neurology 1277 (2014).
11
Eric Scicchitano, Geisinger doctors: Opioids ineffective for chronic pain put patients at risk, The Daily Item (Dec.
7, 2016), http://www.dailyitem.com/news/local_news/geisinger-doctors-opioids-ineffective-for-chronic-pain-put-
patients-at/article_2d66014f-511e-554f-bed5-768886b48616.html (citing, generally, Mellar P. Davis & Zankhana
Mehta, Opioids and Chronic Pain: Where is the Balance? 18 Current Oncology Reports 71 (2016), available at
https://link.springer.com/epdf/10.1007/s11912-016-0558-1)
Insurance companies can play an important role in reducing opioid prescriptions and
making it easier for patients to access other forms of pain management treatment. Indeed, simply
asking providers to consider providing alternative treatments is impractical in the absence of a
supporting incentive structure. All else being equal, providers will often favor those treatment
options that are most likely to be compensated, either by the government, an insurance provider,
or a patient paying out-of-pocket. Insurance companies thus are in a position to make a very
positive impact in the way that providers treat patients with chronic pain.
Adopting an incentive structure that rewards the use of non-opioid pain management
techniques for chronic, non-cancer pain will have many benefits. Given the correlation between
increased supply and opioid abuse, the societal benefits speak for themselves. Beyond that,
incentivizing opioid alternatives promotes evidence-based techniques that are more effective at
mitigating this type of pain, and, over the long-run, more cost-efficient.12 Thus, adopting such
policies benefit patients, society, and insurers alike.
The undersigned Attorneys General serve an important role in combating the opioid
epidemic. As the chief legal officers of our States, we are charged with protecting consumers,
including patients suffering from chronic pain and opioid addiction. Among other things, we are
committed to protecting patients from unfair or deceptive business practices and ensuring that
insurers provide consumers with transparent information about their products and services.
We are thus committed to utilizing all the powers available to our individual offices to
ameliorate the problems caused by the over-prescription of opioids and to promote policies and
practices that result in reasonable, sustainable, and patient-focused pain management therapies.
In the near future, working in conjunction with other institutional stakeholders (such as State
Insurance Commissioners), we hope to initiate a dialogue concerning your members’ incentive
structures in an effort to identify those practices that are conducive to these efforts and those that
are not. We hope that this process will highlight problematic policies and spur increased use of
non-opioid pain management techniques. The status quo, in which there may be financial
incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable. We ask
that you quickly initiate additional efforts so that you can play an important role in stopping
further deaths.
We look forward to having this discussion with you.
Sincerely,
Leslie Rutledge Pamela Jo Bondi
Arkansas Attorney General Florida Attorney General
12
Harrison Jacobs, Pain doctors: Insurance companies won’t cover the alternatives to opioids, Business Insider (Aug.
10, 2016), http://www.businessinsider.com/doctors-insurance-companies-policies-opioid-use-2016-6 (“If you look at
the long-term cost of [opioids], plus monitoring, office visits and drug screenings . . . it’s cheaper long-term to do the
more advanced therapy,”) (quoting Dr. Timothy Deer, co-chair, West Virginia Expert Pain Management Panel).
Derek Schmidt Andy Beshear
Kansas Attorney General Kentucky Attorney General
Jim Hood Hector Balderas
Mississippi Attorney General New Mexico Attorney General
Sean Reyes Mark R. Herring
Utah Attorney General Virginia Attorney General
Patrick Morrisey Mark Brnovich
West Virginia Attorney General Arizona Attorney General
Xavier Becerra George Jepsen
California Attorney General Connecticut Attorney General
Karl. A. Racine Christopher M. Carr
District of Columbia Attorney General Georgia Attorney General
Douglas S. Chin Lisa Madigan
Hawaii Attorney General Illinois Attorney General
Curtis T. Hill Jr. Janet T. Mills
Indiana Attorney General Maine Attorney General
Maura Healey Bill Schuette
Massachusetts Attorney General Michigan Attorney General
Josh Hawley Tim Fox
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Douglas Peterson Adam Paul Laxalt
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Gordon MacDonald Christopher S. Porrino
New Hampshire Attorney General New Jersey Attorney General
Eric T. Schneiderman Josh Stein
New York Attorney General North Carolina Attorney General
Wayne Stenehjem Ellen F. Rosenblum
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Josh Shapiro Wanda Váquez Garced
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Peter Kilmartin Alan Wilson
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Marty Jackley T.J. Donovan
South Dakota Attorney General Vermont Attorney General
Brad Schimel
Wisconsin Attorney General
