How Health Plans Can Break the Cycle of Opioid Abuse

A Texas woman crossed state lines to visit 20 doctors and five pharmacies seeking opioid painkillers. Then her health insurer spotted the pattern.

Opioid pills spilling from a prescription container. GETTY IMAGES

Like many journeys into addiction, Maryanne’s began with pain.

At first it was pain that followed back surgery. Soon, the middle-aged Texas woman found herself with other problems: a continuing struggle to control diabetes, a displaced lumbar disc, gall bladder surgery, another back surgery.

Movement became difficult. She often cried herself to sleep at night, wondering if anyone or anything could help.

She was prescribed opioids – narcotics that act to ease pain – and her journey into addiction started. In eight months last year, she visited emergency rooms 25 times and logged eight inpatient visits in search of prescriptions for opioids. She crossed state lines to visit 20 doctors and five pharmacies, each unaware of the already-prescribed prescriptions for far more narcotics than she should have been taking.

Help came from what might seem an unexpected source: her health insurance company, Blue Cross and Blue Shield of Texas.

Opioid abuse is a widespread problem. Nationally, more than 28,600 people died from opioid drug overdoses in 2014, according to the Centers for Disease Control and Prevention. Six out of 10 overdose deaths involve prescription opioids, the CDC reports.

Maryanne’s overuse of pain medication triggered an alert. (Member privacy is a top concern for Blue Cross and Blue Shield, so this story does not use Maryanne’s real name or other details that might identify her.)

Pain management patients don’t come in with a big ‘A’ on their foreheads

Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas, which are operated by the same company, work together to track members’ medical treatments and prescriptions for signs of potential opioid abuse. Dr. Joseph McClaran, one of the insurer’s medical directors, called Maryanne’s pain management physician in February 2016 as a result of this Controlled Substance Integration program.

Previously unaware of his patient’s overuse, the doctor talked with Maryanne and suggested she call the insurer’s case manager, Debra Keith.

“We had a really good heart-to-heart talk,” Keith said. “People with addictions have ups and downs. We are the window they can open for the support they need. She was relieved that she wasn’t being judged and that we would help her look for answers to her pain management.”

After talking with her doctor and her insurer, Maryanne agreed to see a single doctor for her pain management treatment. The doctor prescribed a strict course of pain relievers at a lesser dosage.

Maryanne told Keith that her real trouble had begun when a doctor wrote a prescription for pain relievers at dosages too strong for her needs. Increasingly, she came to rely on the powerful and dangerous drugs.

Among the opioids Maryanne received: tramadol, hydrocodone with acetaminophen, oxycodone, tapentadol, methadone and acetaminophen with codeine. Four of the drugs are Schedule II – a Drug Enforcement Agency listing of restricted drugs that have a high potential for abuse and that may lead to severe psychological or physical dependence.

Pain management doctors increasingly are seeing patients already using pain medications prescribed by primary care physicians and post-surgery facilities when they seek additional help from the specialists.

Continued use of opioids can lead to addiction and withdrawal symptoms. Medical experts say continued use can change a person’s brain chemistry. Yet it can be difficult for pain management specialists to know which of their patients are more likely to become addicts or if they are using medications they didn’t mention.

“Pain management patients don’t come in with a big ‘A’ on their foreheads,” said Dr. Richard Hurley, a Waco, Texas, specialist who has run a pain management clinic for the last 30 years. He explained that each patient’s needs must be considered individually.

“You have to do psychological testing to see if they are a high risk for addiction,” he said. “You have to look at their family history and understand how they perceive the benefits of narcotics. Using opioid therapy is truly the last option to consider.”

While opiate abuse has made national headlines recently, the Blue Cross and Blue Shield plans have been working on the problem for 12 years. The opioid abuse outreach program reviews members’ doctor visits and prescriptions to help identify anyone who might be struggling with addiction.

Those who need help are contacted to discuss the overuse and to help make a plan to rely upon one pain management doctor who can better coordinate their care. The company launched the Controlled Substance Integration intervention program in 2014 to include working directly with members and doctors to address opioid abuse.

BCBS estimates the program helped it save $267,000 in pharmacy costs in 2015 alone. Meanwhile, in addition to the hard savings members realize through deductibles and out-of-pocket costs, there are the intangible benefits such as helping them better control their pain with a safe drug regimen, and possibly saving lives.

“From a managed care perspective, we strive to help members struggling with addiction understand the seriousness of opioid abuse by offering supportive services and information. We also work with providers to promote safe practices and access to resources,” said Phiyen Tra, director of clinical pharmacy programs for our five state Blue Cross and Blue Shield plans. “It’s important that we all assume social responsibility to address this national epidemic. Lives may hang in the balance.”

In Maryanne’s case, over a three-month period of intervention, it saved about $18,000 in potential ER visits, overused medications and duplicative treatments.

Far more important, Maryanne now appears to be on the road to recovery. She has dramatically reduced her number of ER and in-patient hospital visits since she was introduced to the outreach program. Her physician confirms that she is following her new non-opioid prescription plan.

“Those who consume opiates build up a tolerance for the narcotics, which leads to increasing dosages, which leads to physical dependence and often addiction,” said Dr. McClaran, who treated people admitted for opiate abuse as an emergency room physician before joining the Blue Cross and Blue Shield plans.

“The journey out of addiction can be as physically painful and even more emotionally damaging as entry into it,” McClaran said. “We help members understand their disease and move them toward recovery. The decision they make could possibly mean the difference between life and death.”


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