By Brianna Ehley of PoliticoPro
12/21/2017 09:48 AM EDT

Millions of older Americans are addicted or at high risk of becoming addicted to prescription painkillers, but Medicare doesn’t cover one of the most common treatments to wean people off opioids.

Policy experts and advocates say one of the biggest barriers to addiction treatment for seniors is Medicare’s exclusion of coverage for methadone, the oldest of the three FDA-approved medication assisted therapies treating opioid abuse.

Despite the heightened level of public attention to the opioid epidemic, advocates say there’s very little focus on the senior population. That’s even though the high prevalence of prescription opioid use among seniors, many of whom are on these medications for chronic pain, places them at high risk of abuse.

Almost one third of seniors enrolled in Medicare’s prescription drug benefit received at least one prescription opioid in 2016, and about 500,000 received “high amounts” of opioids that year, according to HHS figures. By 2020, the Substance Abuse and Mental Health Services Administration estimates, 2.7 million older Americans will abuse prescriptions drugs — nearly a 100 percent increase.

Medicare currently covers two treatments to help wean people off opioid addiction — buprenorphine, known as Suboxone, in pill form, as well as naltrexone, an injectable. They both tend to be prescribed to people with a mild to moderate substance use disorder. Experts say methadone is typically prescribed for more severe cases of addiction, and it’s very difficult to switch from it to other forms of medication assisted treatment.

Mark Parrino, the President of the American Association for Treatment of Opioid Dependence, said doctors prefer methadone as a treatment for patients who have been using opioids for longer periods of time and have built up a tolerance.

The coverage issue becomes especially tricky when people who have been receiving methadone treatment for years, covered by some private insurance plans and some states, age into Medicare at 65. At that point, they can either pay out of pocket or switch to a treatment that may be less effective.

“This is a cradle-to-grave issue. People start abusing drugs when they’re very young,” Parrino said. “I don’t think the spigot turns off when they turn 65.”

However, methadone can be prescribed to patients to treat pain under Medicare’s prescription drug benefit, known as Part D. For Medicare to cover it as an addiction treatment, it would have to be added to Medicare Part B, which pays for provider services.

“It’s kind of puzzling why physicians are allowed to prescribe addictive pain medications through Medicare but not allowed to prescribe medications to help them fight a substance use disorder on the other side of that,” said former Rep. Mary Bono, co-founder of the Collaborative for Effective Prescription Opioid Policies, during a briefing at the Capitol last month.

Rep. Richard Neal of Massachusetts, the top Democrat on the House Ways and Means Committee, recently sponsored a bill that would include methadone treatment under Medicare Part B.

“There’s a tendency to assume this crisis is concentrated among young people but it’s crept into the older population,” Neal said.

Advocates have been pushing for Neal’s measure, and one source who works in opioid policy said the bill could be part of a larger package the House Energy and Commerce Committee may take up next year. But so far, it only has Democratic support. The bill hasn’t been scored, but Neal’s office said it was drafted to be budget neutral.

The recent presidential report on opioids, which offered sweeping recommendations for battling the epidemic, made little mention of the older population. However, it did broadly recommend expanding access to medication assisted treatment.

Beyond Medicare coverage, policy experts say the health system needs to be more proactive about flagging older adults at risk of prescription drug abuse. A report from GAO earlier this year found CMS failed to identify hundreds of thousands of seniors at risk of becoming addicted to opioids. CMS had flagged 33,223 Medicare beneficiaries at high risk, while about 727,016 were actually at risk of receiving high doses of the drug, GAO said.

Kathleen Cameron of the National Council on Aging said it can be difficult to detect addiction in older people because the symptoms mimic other problems like confusion, coordination and problems with vision.

“Some older people may not even realize they have a problem,” she said. She added that seniors are at high risk of abuse because there aren’t “a lot of good alternatives to opioids.”

“We see pain a lot in this population,” Cameron. “Because we don’t have many treatments for pain, opioids are often given.”

She said integrating screening into seniors’ primary care would helpful, as well as educating doctors about how to detect prescription abuse in older Americans and educating seniors about the risks of taking these medications.

“Their needs are very different than someone in their 30s and 40s,” Cameron said.