There is little evidence that the opioid epidemic is abating. Debra Houry, Director, CDC’s National Center for Injury Prevention and Control, says it is getting worse, not better.
In the Medicare program, 500,000 patients were on high doses of opioids in 2016, according to a 2017 report from HHS. And one out of every six emergency room visits were opioid related in second quarter 2017, said OM1, a health outcomes company.
But now, two pharmacy benefits managers (PBMs) and the state of Kentucky have developed initiatives to dig deeper into the opioid crisis.
Up next: 3 ways the crisis is being tackled
Stopping Abuse Before it Starts
Express Scripts’ Advanced Opioid Management solution, launched in September, combines pharmacy rules, pharmacist/physician intervention, and patient education and support. [See Table.] The PBM tested this approach in a pilot program with more than 100,000 members who are new to opioid therapy. It found a 38% reduction in hospitalizations and a 40% decrease in emergency room visits in the intervention group, who received an educational letter, versus a control group during 6 months of follow-up.
A subset of the intervention group also received a counseling call from a pharmacist. There was a 19% decrease in length of supply of opioid prescriptions during the follow-up period.
“By using data analytics, a specialized care model, fraud, waste and abuse management capabilities, and behavioral science, we will do more to help stop abuse before it starts,” says Glen Stettin, MD, Senior Vice President, Clinical, Research and New Solutions for Express Scripts.
Prime Therapeutics Adds Care Managers to the Equation
Patrick Gleason, Senior Director, Health Outcomes for Prime Therapeutics, says that a new paradigm is changing the treatment of patients with pain. Instead of setting a goal of totally eliminating pain, providers should focus on keeping patients safe and avoiding the risk of dependence while decreasing pain, he says.
Using predictive modeling, Prime Therapeutics is using a program that combines:
- Concurrent drug utilization review (cDUR) which flags potential dispensing problems for pharmacists to address, such as duplicate prescriptions.
- Utilization management to establish quantity limits and prior authorization.
- Retrospective DUR using Prime Therapeutics’ clinical rules to notify prescribing physicians of patients who are at high risk and require attention.
- Guided Health Care Program that includes case management, hard edits, quantity limits, and a lock-in program.
The program contributed to a 71% reduction in high-risk opioid use and a 16% decrease in opioid claims for Prime’s commercial book of business between the first halves of 2012 and 2017.
Kentucky Takes Aim at Those at Risk
WellCare, Kentucky’s Medicaid insurer, completed a 6-month pilot program of 1,300 participants who were at-risk for opioid misuse or abuse in October. The program resulted in a 50% reduction in opioid dispensing in situations of potential abuse and 35% and 30% decreases in dispensing of a cyclobenzaprines and benzodiazepines, respectively. Kentucky ranks third in opioid addiction in the country.
WellCare paired participants with one provider, one pharmacist, and a care manager specializing in substance abuse treatment who also provided social and other support services.
Howard Shaps, MD, WellCare’s Senior Medical Director, says the use of care managers who focus on social issues related to opioid abuse is a key feature of the program.