The magnitude of the opioid problem is unfathomable, and touchescountless lives. From 1999 to 2010, the amount of prescriptionopioids sold to hospitals, pharmacies and doctors’ offices in theU.S. almost quadrupled.1,2,3 Yet, during that time,there had not been a reduction in the amount of pain that Americansreported.4,5 Moreover, during that time,prescription opioid overdose deaths increased at a similarrate.

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

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The CDC reports:

  • As many as 1 in 4 patients receiving long-term opioid therapy ina primary care setting struggles with opioidaddiction.8,9,10,11 In 2014, nearly 2 million Americanseither abused or were dependent on prescription opioid painrelievers.

  • The supply of prescription opioids remains high in theU.S.12 From 2007 to 2012, the rate of opioidprescribing steadily increased among specialists likely to manageacute and chronic pain, with opioids prescribed at the highestrates for pain medicine, surgery, and physicalmedicine/rehabilitation.13

  • Though rates of opioid prescribing have increased amongspecialists, primary health care providers account for half of allopioid pain relievers dispensed.13 These primary careproviders report that they are concerned about opioid-related risksof addiction and overdose, as well as insufficient training in painmanagement. Long-term use of opioid pain relievers for chronic paincan be associated with abuse and overdose, particularly at higherdosages.

The problem is undeniable. So, what do HR executives and thebrokers who support them need to know about opioids to help improvehealth outcomes and lower costs due to unnecessary use of theseoften harmful medications? While the answer is not simple, thereare three primary solutions that can be applied across anyorganization:

  1. Design workplace protocols to include prevention, education andawareness strategies

  2. Know what to ask your PBM partner regarding strategicprescription 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’twork. According to the National Institute of Health Science Panelfindings in 2004, “Programs that rely on scare tactics to preventproblems are not only ineffective, but may have damagingeffects.”

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

Workplace protocols

In the workplace, employers and managers should be aware ofaddiction signs and symptoms. U.S. News & World Report offersexcellent advice in its article “Addictionin the Workplace: Tips for Employers,” published in August of2016. The article identifies four concerns to watch for on the job:Attendance problems; performance issues; strained workrelationships; and behavioral issues. It notes a number of signs ofaddiction, which include lack of physical coordination, slurredspeech, and avoidance of colleagues and supervisors.

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

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

  • Educate yourself regarding substance abuse disorders, and theappropriate way to approach an employee who may be affected.Recognize that many individuals struggling with addiction may denythat there is a problem. Reach out to an expert within theorganization, if one is available, for advice on how best to workwith an employee to get to the root of the problem when addictionis 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, physicaltherapy, and substance abuse treatment as part of employee medicalbenefits so that workers have the tools they need to prevent andcombat addiction.

To help prevent substance abuse and address suspectedprescription misuse, the FDA has published guidelines, which HRprofessionals, plan sponsors and brokers can share withemployees:

  1. Always follow the directions carefully when taking prescriptionmedication.

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

  3. Never stop taking medication on your own.

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

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

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

  7. Talk honestly with your doctor about any history of substanceabuse.

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

In addition to using medications as prescribed, it is importantto understand what dangerous combinations can be harmful. Accordingto the National Institute on Drug Abuse, opioids should not be usedwith substances that cause central nervous system (CNS) depression,including alcohol, antihistamines, barbiturates, benzodiazepines,and general anesthetics. CNS depressants should not be used withother 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 theirbrokers, pharmacy benefit managers (PBMs) should be takingproactive measures to oversee the prescribing of opioids, andprevent inappropriate or dangerous prescribing. Here are some ofthe ways PBMs can address fraud waste and abuse, both before andafter a member fills a prescription.

  • Starter dose programs

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

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To ensure opioids are an appropriate treatment for the member, astarter dose should initially be dispensed. If, after the trialfill, the prescriber determines that another fill is required, themember would then be able to obtain up to a 30-day supply. Quantitycontrol helps reduce the risk of opioid abuse and prolonged usethat’s unnecessary. It also prevents and limits “medicine cabinettheft,” which is often caused by excess supplies of opioids lyingaround the house and getting into the hands of individuals withouta prescription who may be struggling with addiction.

  • Point of sale edits

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

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To help prevent substance abuse, pharmacists should not be ableto dismiss POS alerts and proceed with filling a prescriptiondespite safety concerns. These alerts should be addressedbefore the medication is dispensed. This can protectmembers from being provided with dangerously high doses of a drugor obtaining excessive amounts of controlled substances throughpractices such as “doctor shopping” in which addicted individualsmay fill prescriptions — from multiple prescribers — to get aroundquantity limits for potentially addictive drugs such asopioids.

  • Quantity limits

Many medications have a high risk of side effects, adverseevents or the potential for addiction when taken above the amountas recommended by the manufacturer or FDA. For opioids, addictionand overdose are not the only dangers. This class of drugs can alsocause respiratory depression, compromised liver function and evenbrain damage. To promote safe and appropriate use of suchmedications, the amount of medication that can be dispensed to amember within a specific time period should be limited by the PBM’sclaim processing system (at the point of sale) in the form ofquantity limits. This helps to prevent problems before medicationis dispensed. These general quantity limitations should bedetermined based on the published guidelines (and morphineequivalent dosing) to proactively protect members.

  • Proactive provider communications

It is essential for PBMs to communicate with prescribers whenquestionable utilization patterns are identified, because there isno one-size-fits-all response. A PBM’s pharmacist should workdirectly with the prescribing physician to obtain clinicalinformation required to ensure the member is taking an appropriatemedication or dose. With a complete understanding of the member’scase, and reasoning for the prescription, the prescriber and PBM’spharmacist can work together to determine whether a member’s opioiduse is appropriate and beneficial, and what next steps should betaken. It is never wise to simply cut a member off from an opioidmedication, and it is not safe to do so. Members who need to betransitioned to a lower dose of opioids, or to discontinue themaltogether, must have their doses titrated down under a doctor’ssupervision.

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

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Looking at the member holistically is essential. For instance,members may need assistance in accessing mental health services orphysical therapy to help manage their condition, not just aprescription opioid. PBMs must consider the overall health of themember and add empathetic value and insight to each individualcase. All key parties must come together to optimally manage healthoutcomes.

Ongoing utilization review and oversight

Utilization review for efficacy, safety and appropriateness mustbe applied in addition to a comprehensive clinical oversightprograms. This includes the PBM’s retrospective review ofutilization data, as well as the awareness of new guidelines orchanges published by manufacturers or the FDA. Together thesepieces maximize member health outcomes by making sure members areusing the most effective medication available that offers the leastrisk.

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Retrospective drug utilization review processes identifytherapeutic and clinical issues using historical claims data toanalyze patterns in utilization from both the member’s and theprescriber’s perspectives. This retrospective review monitorscontrolled substance usage, targeted therapeutic classes,utilization trends, and physician prescribing patterns. Identifiable issues include safety concerns, excessive or improperusage of medication and potential therapeutic alternatives to helplimit risk of abuse and addiction.

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

Conclusion

Embracing a philosophy of member education, safety andprotection is paramount. This means implementing changes and newpolicies for opioid dispensing at retail pharmacies and mail order.Limits on opioid medications are a must. Research shows that thelonger a person takes an opioid, even by prescription, the higherthe risk of addiction and overdose. This impacts not only theindividual but their families, colleagues and friends. Bypreventing unnecessary and dangerous dispensing of opioids, healthoutcomes improve and prescription drug plan costs and trend comedown.

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Prescription opioids have their place when prescribedresponsibly to members with a genuine need. Often, there are safeand effective alternatives that should be considered before movingstraight to an opioid to promote pain management. More care andoversight is necessary to reduce our reliance on opioids and toensure we are preventing rather than promoting contraindicated use,dependence and overdose.

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  1. Centers for Disease Control andPrevention, National Centerfor Injury Prevention and Control, Division of UnintentionalInjury Prevention. Understandingthe Epidemic Drug overdose deaths in the United States continue toincrease in 2015. Atlanta, GA: CDC; 2017.
  2. CDC. Wide-ranging online data for epidemiologic research(WONDER). Atlanta, GA: CDC, National Center for Health Statistics;2016. Available at http://wonder.cdc.gov.
  3. Paulozzi LJ, Jones CM, Mack KA, Rudd RA. VitalSigns: Overdoses of Prescription Opioid Pain Relievers—UnitedStates, 1999—2008. MMWR 2011; 60(43):1487-1492.
  4. Chang H, Daubresse M, Kruszewski S, et al. Prevalence andtreatment of pain in emergency departments in the United States,2000 – 2010. Amer J of Emergency Med 2014; 32(5): 421-31.
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  6. Howard G. Birnbaum, PhD Alan G. White, PhD MattSchiller, BA Tracy Waldman, BAJody M. Cleveland, MS CarlL. Roland, PharmD. Societal Costs of Prescription Opioid Abuse,Dependence, and Misuse in the United States. PainMedicine, Volume 12, Issue 4, 1 April 2011, Pages 657–667
  7. Shah A, Hayes CJ, Martin BC. Characteristics of InitialPrescription Episodes and Likelihood of Long-Term Opioid Use —United States, 2006–2015. MMWR Morb Mortal Wkly Rep2017;66:265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1
  8. Centers for Disease Control andPrevention, National Centerfor Injury Prevention and Control, Division of UnintentionalInjury Prevention. PrescriptionOpioids Addiction and Overdose. Atlanta, GA: CDC; 2017.
  9. Banta-Green CJ, Merrill JO, Doyle SR, Boudreau DM, Calsyn DA.Opioid use behaviors, mental health and pain—development of atypology of chronic pain patients. Drug Alcohol Depend2009;104:34–42.
  10. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors fordrug dependence among out-patients on opioid therapy in a large UShealth-care system. Addiction 2010;105:1776–82.
  11. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD.Substance use disorders in a primary care sample receiving dailyopioid therapy. J Pain 2007;8:573–82.
  12. Centers for Disease Control and Prevention. Vital Signs:Variation Among States in Prescribing of Opioid Pain Relievers andBenzodiazepines — United States, 2012. MMWR 2014;63(26):563-568.
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