From policy to practice: California’s next step in the opioid fight

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OPINION: California has made national headlines for its leadership in confronting the opioid crisis. Governor Gavin Newsom has been clear about the state’s commitment: “We have an all-hands-on-deck strategy focused on preventing tragedy, connecting people with treatment, and prioritizing harm reduction strategies.” These words reflect the kind of comprehensive, evidence-based approach that has the potential to save thousands of lives.

Yet on the ground, Medi-Cal’s practices tell a different story—one that threatens to undermine the very progress California has pledged to lead.

In 2023 alone, California lost more than 8,000 people to opioid overdoses. Another 22,000 ended up in emergency rooms. These numbers are not abstractions—they represent families devastated, communities destabilized, and a healthcare system under relentless strain. The state has invested in prevention, treatment, and harm reduction, but the foundation of any effective opioid strategy must be how we manage pain in the first place.

California’s Medical Board has issued guidelines that reflect national best practices: start with non-pharmacological and non-opioid medications, and use opioids only when alternatives fail, are not tolerated, or are not clinically appropriate. This science-based framework prioritizes patient safety while recognizing the importance of individualized care.

Here’s the issue: Medi-Cal, the state’s largest insurer, has created a preference structure that directly contradicts these guidelines. FDA-approved, evidence-based non-opioid treatments are either excluded from the formulary or placed behind bureaucracy such as prior authorization or step therapy. In practice, it is easier for patients and providers to access opioids—the very drugs California is working so hard to reduce—than safer alternatives our own policies recommend.

When a system makes opioids the path of least resistance while putting barriers in front of safer alternatives, it doesn’t just fail patients—it creates openings for abuse. Federal authorities have already cracked down on schemes built around medically unnecessary opioid prescriptions and billing. California shouldn’t leave its own healthcare system vulnerable to the same bad actors by keeping non-opioid options locked behind red tape.

The patient consequences are immediate. Delays in access to non-opioid treatments often mean patients in pain are left with opioids as the “path of least resistance.” These administrative barriers increase the risk of dependency, undermine trust in the healthcare system, and ultimately raise long-term costs as conditions worsen and emergency interventions escalate.

This is not about waiting for new breakthroughs. The science is clear, the treatments exist, and California has endorsed them in principle. The problem is access. It is akin to installing fire alarms and stocking fire extinguishers but locking them away during a fire.

California has an opportunity—indeed, an obligation—to align practice with policy. Doing so would make the state a true national model for tackling the opioid epidemic.

Three immediate actions would have an outsized impact:

• Add novel non-opioid treatments to the Medi-Cal formulary. Every FDA-approved non-opioid alternative that aligns with Medical Board guidelines should be available as a first-line treatment.
• Eliminate access disparities. Remove prior authorization and step-therapy requirements for non-opioid treatments while maintaining rigorous oversight for opioids.
• Reverse the preference structure. Ensure that non-opioid alternatives are easier—not harder—to access than opioids.

California has already shown the courage to lead on the opioid crisis. Now it must finish the job. By making non-opioid pain treatments as accessible—or even more—than opioids, the state can translate Governor Newsom’s vision into reality.

This is not only about reducing overdose deaths; it is about building a healthcare system that puts patients first, values science over outdated bureaucracy, and saves lives instead of risking them. The tools are here. The policy is written. What’s missing is action. If California acts now, it won’t just meet the moment—it will set the national standard for how to finally turn the tide against opioids.

Terry Martin is a Board Member of California Consumer Voice, an organization dedicated to educating and advocating for consumers across the state to ensure their voices shape the policies that affect their lives.