The magnitude of the opioid problem is unfathomable, and touches countless lives. From 1999 to 2010, the amount of prescription opioids sold to hospitals, pharmacies and doctors’ offices in the U.S. almost quadrupled.^1,2,3 Yet, during that time, there had not been a reduction in the amount of pain that Americans reported.^4,5 Moreover, during that time, prescription opioid overdose deaths increased at a similar rate.

Employee productivity has also been greatly impacted by opioid abuse. These highly addictive and often over-prescribed medications have had a profound impact on families and businesses. Reports show that individuals with addiction are far more likely to be sick or absent, or to use workers' compensation benefits. According to one study, prescription opioid abuse cost employers more than $25 billion in 2007.⁶ Moreover, in a study published by the Centers for Disease Control and Prevention (CDC), the “likelihood of chronic opioid use increased with each additional day of medication supplied starting with the third day,” and some of the “sharpest increases in chronic opioid use [were] observed after the fifth and thirty-first day on therapy.”⁷

The CDC reports:

• As many as 1 in 4 patients receiving long-term opioid therapy in a primary care setting struggles with opioid addiction.^8,9,10,11 In 2014, nearly 2 million Americans either abused or were dependent on prescription opioid pain relievers.

• The supply of prescription opioids remains high in the U.S.¹² From 2007 to 2012, the rate of opioid prescribing steadily increased among specialists likely to manage acute and chronic pain, with opioids prescribed at the highest rates for pain medicine, surgery, and physical medicine/rehabilitation.¹³

• Though rates of opioid prescribing have increased among specialists, primary health care providers account for half of all opioid pain relievers dispensed.¹³ These primary care providers report that they are concerned about opioid-related risks of addiction and overdose, as well as insufficient training in pain management. Long-term use of opioid pain relievers for chronic pain can be associated with abuse and overdose, particularly at higher dosages.

The problem is undeniable. So, what do HR executives and the brokers who support them need to know about opioids to help improve health outcomes and lower costs due to unnecessary use of these often harmful medications? While the answer is not simple, there are three primary solutions that can be applied across any organization:

1. Design workplace protocols to include prevention, education and awareness strategies

2. Know what to ask your PBM partner regarding strategic prescription drug management

3. Point of sale edits, including duplicate therapy edits

4. Proactive provider communications

5. Quantity limits

6. Starter dose programs

7. Be aware of ongoing utilization review and oversight

Prevention and awareness strategies

When it comes to prevention and awareness, scare tactics don’t work. According to the National Institute of Health Science Panel findings in 2004, “Programs that rely on scare tactics to prevent problems are not only ineffective, but may have damaging effects.” 

The National Institute of Health’s National Institute on Drug Abuse offers prevention recommendations for youth and families, where education must begin. The principles shared are intended to help parents, educators and community leaders proactively address the issue of addiction. 

Workplace protocols 

In the workplace, employers and managers should be aware of addiction signs and symptoms. U.S. News & World Report offers excellent advice in its article “Addiction in the Workplace: Tips for Employers,” published in August of 2016. The article identifies four concerns to watch for on the job: Attendance problems; performance issues; strained work relationships; and behavioral issues. It notes a number of signs of addiction, which include lack of physical coordination, slurred speech, and avoidance of colleagues and supervisors. 

Employers must carefully consider their next steps before speaking to an employee if addiction in the workplace is suspected. While it is important to discuss possible substance abuse with the employee one-on-one, doing so without an action plan in place can be premature. Consider some of the following key elements to help effectively address addiction, and ensure that employees have access to the help they need: 

• Have clearly defined drug policies in place. These create clear expectations regarding what is and is not acceptable in the workplace, and what steps an employer will take when addiction is suspected on the job. They can also help clearly define the rights and obligations of all parties involved. 

• Educate yourself regarding substance abuse disorders, and the appropriate way to approach an employee who may be affected. Recognize that many individuals struggling with addiction may deny that there is a problem. Reach out to an expert within the organization, if one is available, for advice on how best to work with an employee to get to the root of the problem when addiction is suspected. 

• Provide resources to employees on the safe use of opioids, preventing substance abuse, and how to get help if they need it. Offer services such as behavioral health coverage, physical therapy, and substance abuse treatment as part of employee medical benefits so that workers have the tools they need to prevent and combat addiction. 

To help prevent substance abuse and address suspected prescription misuse, the FDA has published guidelines, which HR professionals, plan sponsors and brokers can share with employees:

1. Always follow the directions carefully when taking prescription medication.

2. Don't increase or decrease doses without speaking to your doctor first.

3. Never stop taking medication on your own.

4. Don't crush or break pills (especially important if the pills are time-released).

5. Be clear about the drug's effects on driving and other daily tasks.

6. Learn about possible interactions of the prescription medicine with alcohol and other prescription and over-the-counter (OTC) drugs.

7. Talk honestly with your doctor about any history of substance abuse.

8. Never allow other people to use your medications and don't take theirs. 

In addition to using medications as prescribed, it is important to understand what dangerous combinations can be harmful. According to the National Institute on Drug Abuse, opioids should not be used with substances that cause central nervous system (CNS) depression, including alcohol, antihistamines, barbiturates, benzodiazepines, and general anesthetics. CNS depressants should not be used with other substances that depress the CNS, such as alcohol, prescription opioid pain medicines, and some over-the-counter (OTC) cold and allergy medications. 

Strategic prescription drug management

Supplementing the education delivered by HR executives and their brokers, pharmacy benefit managers (PBMs) should be taking proactive measures to oversee the prescribing of opioids, and prevent inappropriate or dangerous prescribing. Here are some of the ways PBMs can address fraud waste and abuse, both before and after a member fills a prescription.

• Starter dose programs

Because of the addictive nature of prescription opioids — including oxycodone, hydrocodone, morphine, and methadone — and certain other medications, it is prudent and wise to implement proactive safety measures, such as a starter dose program for the opioid therapeutic class. While most pain medications are prescribed for a 30-day supply, in acute situations, often only 3 to 7 days’ worth of medication is actually used, either due to improvement in symptoms or the development of side effects.

To ensure opioids are an appropriate treatment for the member, a starter dose should initially be dispensed. If, after the trial fill, the prescriber determines that another fill is required, the member would then be able to obtain up to a 30-day supply. Quantity control helps reduce the risk of opioid abuse and prolonged use that’s unnecessary. It also prevents and limits “medicine cabinet theft,” which is often caused by excess supplies of opioids lying around the house and getting into the hands of individuals without a prescription who may be struggling with addiction. 

• Point of sale edits

PBMs can also take steps to protect members by putting clinical rules in place at the point of sale (POS). When you begin with POS alerts, rather than evaluating claims retroactively, you help protect members before problems occur. Point-of-sale edits for safety can include duplicate therapy, high dose, quantity limit, prior authorization, cumulative dose, and others.

To help prevent substance abuse, pharmacists should not be able to dismiss POS alerts and proceed with filling a prescription despite safety concerns. These alerts should be addressed before the medication is dispensed. This can protect members from being provided with dangerously high doses of a drug or obtaining excessive amounts of controlled substances through practices such as “doctor shopping” in which addicted individuals may fill prescriptions — from multiple prescribers — to get around quantity limits for potentially addictive drugs such as opioids.

• Quantity limits

Many medications have a high risk of side effects, adverse events or the potential for addiction when taken above the amount as recommended by the manufacturer or FDA. For opioids, addiction and overdose are not the only dangers. This class of drugs can also cause respiratory depression, compromised liver function and even brain damage. To promote safe and appropriate use of such medications, the amount of medication that can be dispensed to a member within a specific time period should be limited by the PBM’s claim processing system (at the point of sale) in the form of quantity limits. This helps to prevent problems before medication is dispensed. These general quantity limitations should be determined based on the published guidelines (and morphine equivalent dosing) to proactively protect members.

• Proactive provider communications

It is essential for PBMs to communicate with prescribers when questionable utilization patterns are identified, because there is no one-size-fits-all response. A PBM’s pharmacist should work directly with the prescribing physician to obtain clinical information required to ensure the member is taking an appropriate medication or dose. With a complete understanding of the member’s case, and reasoning for the prescription, the prescriber and PBM’s pharmacist can work together to determine whether a member’s opioid use is appropriate and beneficial, and what next steps should be taken. It is never wise to simply cut a member off from an opioid medication, and it is not safe to do so. Members who need to be transitioned to a lower dose of opioids, or to discontinue them altogether, must have their doses titrated down under a doctor’s supervision.

The use of pharmacogenetics can also help. By understanding a member’s genetic makeup and its effect on how they metabolize certain medications, we can go one step further in improving outcomes and ensuring that the member is taking the medication that is most effective for them. For example, in a situation where a member receives no pain relief from morphine, the cause may be that the member is unable to metabolize the drug. Without knowing why the medication is ineffective, a prescriber could increase dosage, seeking the expected relief while unintentionally increasing the member’s risk for overuse or addiction. 

Looking at the member holistically is essential. For instance, members may need assistance in accessing mental health services or physical therapy to help manage their condition, not just a prescription opioid. PBMs must consider the overall health of the member and add empathetic value and insight to each individual case. All key parties must come together to optimally manage health outcomes. 

Ongoing utilization review and oversight

Utilization review for efficacy, safety and appropriateness must be applied in addition to a comprehensive clinical oversight programs. This includes the PBM’s retrospective review of utilization data, as well as the awareness of new guidelines or changes published by manufacturers or the FDA. Together these pieces maximize member health outcomes by making sure members are using the most effective medication available that offers the least risk. 

Retrospective drug utilization review processes identify therapeutic and clinical issues using historical claims data to analyze patterns in utilization from both the member’s and the prescriber’s perspectives. This retrospective review monitors controlled substance usage, targeted therapeutic classes, utilization trends, and physician prescribing patterns.  Identifiable issues include safety concerns, excessive or improper usage of medication and potential therapeutic alternatives to help limit risk of abuse and addiction. 

When guidelines are modified or updated because of changes in the market or new guidance, the PBM should also adjust clinical programs and protocols. As an HR representative or broker supporting a client’s HR department, it is important to be aware of changes being made by the PBM so you can be certain that the programs in place for employees are comprehensive and up to date.

Conclusion

Embracing a philosophy of member education, safety and protection is paramount. This means implementing changes and new policies for opioid dispensing at retail pharmacies and mail order. Limits on opioid medications are a must. Research shows that the longer a person takes an opioid, even by prescription, the higher the risk of addiction and overdose. This impacts not only the individual but their families, colleagues and friends. By preventing unnecessary and dangerous dispensing of opioids, health outcomes improve and prescription drug plan costs and trend come down.

Prescription opioids have their place when prescribed responsibly to members with a genuine need. Often, there are safe and effective alternatives that should be considered before moving straight to an opioid to promote pain management. More care and oversight is necessary to reduce our reliance on opioids and to ensure we are preventing rather than promoting contraindicated use, dependence and overdose. 

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