The opioid epidemic continues to devastate communities across California. In 2023 alone, California providers wrote more than 13 million prescriptions for opioids, an enormous volume that represents millions of opportunities for potential misuse, dependency, and addiction.

As a licensed vocational nurse who has worked in emergency rooms and mental health settings throughout Southern California, I’ve seen the impact of Substance Use Disorder (SUD). I’ve treated overdose patients, counseled families who’ve lost loved ones, and cared for individuals fighting to stay in recovery.

While California has taken major strides in addressing the opioid epidemic and decreasing the risk of unnecessary opioid prescriptions for patients, a major gap exists for some of the most vulnerable populations.

The state’s Medical Board has issued clear, evidence-based guidelines that recommend starting with non-opioid medications for acute pain management and proceeding to opioids only when alternatives fail or aren’t appropriate. Unfortunately, actual coverage policies for Medi-Cal — the state’s low-income health insurance program — directly contradict these guidelines.

Medi-Cal patients seeking treatment for acute pain face barriers to obtaining safer non-opioid approaches first. Non-opioid pain medications require prior authorization from Medi-Cal’s prescription drug program, which may require patients to use another drug first to see if it is effective before moving on to the medication the patient and their provider prefer. These hurdles can take days to navigate.

Meanwhile, opioids don’t require prior authorization, and there are non-opioid alternatives that aren’t on the Medi-Cal Rx Contract Drugs List, which therefore are subjected to a complex and lengthy prior authorization process. In some cases the provider must provide evidence of the patient’s substance abuse history, family history or fear of Opioid Use Disorder.     

The result? A system where the dangerous option is easier to access than the safer one.

Medi-Cal’s defense of this policy may likely center on cost containment and formulary management. Prior authorization exists, in theory, to ensure medications are medically necessary and cost-effective. Medi-Cal may argue that requiring prior authorization for newer non-opioid pain medications protects the program from unnecessary spending on expensive drugs when cheaper alternatives are available, including generic opioids.

Opioids absolutely have a place in pain management. They’re critical tools when used appropriately. Yet so do non-opioid options, including NSAIDs like Ibuprofen and Naproxen and newer FDA-approved medications, which offer alternatives for patients who need to avoid both opioids and NSAIDs due to heart conditions or a history of stomach ulcers.

When a patient comes to the emergency room with serious pain, such as a kidney stone, injury, or post-surgical pain, doctors and nurses should have the option to prescribe a non-opioid medication for their specific situation and when appropriate. However, if that patient has Medi-Cal, doctors would be forced to wait for approval while they suffer or end up prescribing opioids because those are immediately available.

Every unnecessary opioid prescription is a potential entry point into addiction. For someone with no history of substance use, it could be their first exposure. For someone in recovery, it could trigger a relapse. Tragically, the toll on Californians has been devastating, with more than 8,000 overdose deaths and another 22,000 emergency room visits in 2023.

The solution is straightforward: California needs to implement “pain parity,” ensuring that non-opioid pain medications are at least as accessible as opioids. This means removing prior authorization requirements for evidence-based non-opioid treatments and making them available as first-line options for Medi-Cal patients.

Effective non-opioid pain treatments already exist. California has already endorsed them through the Medical Board guidelines. What’s missing is access.

If leaders are serious about ending the opioid crisis, we need to prevent unnecessary opioid exposure before it starts. That means making safer alternatives the default, not the fallback. 

Gov. Gavin Newsom has called the opioid crisis an “all-hands-on-deck” emergency, and Dr. Michelle Baas, director of the Department of Health Care Services, understands the importance of evidence-based public health policy. They’ve both shown they can lead on difficult public health challenges. 

Now they can align Medi-Cal coverage with the Medical Board’s own guidelines to make non-opioid medications as accessible as opioids and give doctors the tools to manage pain safely. California’s pain management guidelines already point the way forward. Closing this gap between policy and practice could save thousands of lives.

Jackie Perez is a licensed vocational nurse in Southern California.