Is there a way to keep opioids out of the hands of all but the patients who legitimately need them?
When Dr. Clay Marsh looks out the windows at West Virginia University, he sees a landscape of rolling hills nestled in the Appalachian Mountains. The scenery is breathtaking but deceiving, as it conceals one of the worst public health crises in modern times: rampant and deadly abuse of opioid pain medication.
From coast to coast, the highly potent and addictive drugs are ravaging bodies, filling emergency rooms and forcing the full spectrum of health care delivery to develop solutions to stem the tide.
West Virginia leads the nation in opioid deaths, with 36 per 100,000 people in 2015, according to a report by the West Virginia Department of Health and Human Resources. It’s followed by New Hampshire (31 per 100,000) and Ohio (25 deaths per 100,000). The national average is 10.4 deaths per 100,000 people.
It’s easy amid these bleak statistics to believe a solution is impossible. But Marsh, WVU’s vice president and executive dean for health sciences, disagrees. He was part of a three-person panel that testified about opioid abuse and treatment last October before the Congressional Academic Medicine Caucus.
To Marsh and others working to solve the epidemic, the solution lies in bringing together various players across the health system — physicians, behavioral health specialists, pharmacists and insurers — along with social service providers to help with jobs and housing.
“The opioid epidemic is an iceberg — we only see the tip,” Marsh says. “What is visible is merely a small part of the much larger foundation of the drug issue. Social isolation, fear, despair, hopelessness, loss of connection and purpose make up that foundation. It’s time for us to think about collaborating and not competing. You can call the right people to the table and create something really special.”
Since the opioid epidemic took hold, the health care industry’s priority has been treating people already deep in the throes of addiction and at risk of dying from an overdose. For example, naloxone, formerly a prescription-only medication to rapidly reverse opioid overdose, is now widely available at pharmacies without a prescription, and first responders typically carry it with them in case they encounter someone who appears to have overdosed.
But over time, the focus has widened to examine how an addiction takes root in the first place. Is there a way to keep opioids out of the hands of all but the patients who legitimately need them? Traditionally, opioids like hydrocodone, oxycodone and codeine had only been prescribed after surgery or injury, or for a serious health condition such as cancer.
The crisis developed as doctors began to prescribe them for chronic conditions that are painful but not life-threatening, such as back pain or osteoarthritis, according to the Centers for Disease Control and Prevention. Not only did patients have more access to the drugs, but more pills in circulation meant more potential for abuse by people for whom they weren’t prescribed. In one case, a congressional investigation into the practice of “pill-dumping” found that over the past decade, 20.8 million prescription pain killers were shipped to two pharmacies in a southern West Virginia town with a population of just 2,900 people.
“It all starts with the physician’s pen,” says Dr. Matthew Fontana, divisional senior vice president and chief medical officer for pharmacy at Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas. “The change in prescribing patterns gave birth to the opioid epidemic. First there was acute pain medication overprescribing. Then most people keep them even after they don’t need them, which is fertile ground for diversion of that medication. Also, we have the fact that for certain people, just three or four pills is enough to put them into a pattern of prescription abuse.”
The Blue Cross and Blue Shield Association has taken the position that opioids should not be the first or second choice of pain reliever for most patients. Its member companies promote alternatives that include more optimal use of non-opioid prescription painkillers and existing over-the-counter pain medications.
In addition, the Blues Plans in Illinois, Montana, New Mexico, Oklahoma and Texas developed an approach called Controlled-Substance Integration. CSI is a two-pronged approach, one focusing on primary care physicians and prescribers and the other on the Plans’ members who have the pharmacy benefit. This integrated approach leverages the insurer’s vast amount of patient and prescriber data to identify patterns that could lead to abusive behavior.
In the physician and prescriber program, the Plans use prescribing data analytics to identify health care providers who write a high number of opioid prescriptions compared with their peers. The Plans intervene with those providers, alerting them to the data showing how they compare with their peers on opioid prescribing. They also are given information about proper pain medication prescribing, based on the CDC’s guidelines.
The program began in September 2016, and eight months later there was an average reduction of 15 mg in the prescribed morphine equivalent daily dose (the standard use to measure opioid use) by providers contacted through the program.
One of the cases identified through the program was an Illinois physician prescribing an average of 299 mg per day of morphine equivalent dose. He wrote more than 3,000 opiate prescriptions within 12 months, amounting to 390,000 pills, says Phillip Yoo, a clinical pharmacist for the five Plans. The findings were reported to the Drug Enforcement Agency, which had received other complaints about that same physician, and eventually his license was placed on probation for two years, among other interventions.
The prescriber program is a companion to a member program. The insurer uses claims data to identify patients filling a high volume of opioid prescriptions or making frequent emergency department visits. Those patients’ cases are then presented to a committee made up of the insurer’s medical directors, behavioral health clinicians, pharmacy, case management and special investigations departments.
For certain people, just three or four pills is enough to put them into a pattern of prescription abuse.
Since the launch of the CSI member program in 2015, more than 150 such cases have been presented to the committee. Where appropriate, individualized interventions, including provider outreach and behavioral health support, have been provided. In addition, opioid prescriptions declined 13 percent from 2012 to 2016 across Blues Plans. The panel also identified 500 other member cases for monitoring. If the behavior continues, they could be candidates for intervention.
Fontana hopes these two programs — and others — will eventually include data from other sources in addition to the insurer’s own claims data so they can reach even more people who are at risk for or already addicted to opioids.
“If you take the lid off people’s lives on opioids, it’s a living hell. It is an absolute catastrophe for them,” he says. “They run through their money, their relatives’ money. We like to do things we can control, like monitor prescriptions, but some of what’s going to get them better is messy. We need to drive solutions that are boots-on-the-ground focused.”
Both Fontana and WVU’s Marsh stress the need for collaboration, as does a new report by the trade group America’s Health Insurance Plans. It released a benchmark study in February from its STOP Initiative (Safe, Transparent Opioid Prescribing). STOP was developed by a work group of more than 40 insurance providers to encourage prescribers to follow the CDC prescribing guidelines.
Looking at claims data from 2009 to 2013, AHIP assessed performance on six of the 12 CDC recommendations. That baseline analysis will be used to measure the ongoing progress of STOP, according to Kate Berry, AHIP’s senior vice president of clinical affairs.
The promising results were that the majority of opioid prescriptions for chronic pain were for immediate-release opioids, which the CDC recommends as they are less likely to cause an overdose. But the report did find a few measures to improve, including:
While some providers may argue that their prescribing habits aren’t the business of health insurers, Berry disagrees. She says STOP is a way to help clinicians who may not realize they are out of the recommended norms.
“The way the plans are doing this is in collaboration with the clinicians. They are supporting the clinicians by providing this information,” Berry says. “But there is no question we need a culture change. This epidemic is so multifaceted — from reducing prescriptions to working with law enforcement — and there is no silver bullet. This is just one way we can work together to make a dent and turn the tide.”