How to conduct a current state assessment of opioid risk and misuse in your population
Opioid addiction has reached crisis levels in the U.S., affecting not only individuals and families but communities and employers, especially in the context of pain management. Consider the following statistics:
- Opioid prescriptions per person have tripled from 1999 to 2015, with the typical prescription dose averaging 18 days before the patient revisits a care provider, according to both the Center for Disease Control (CDC) Opioid Prescribing Data and a July 2017 report.
- The United States consumes approximately 80% of the global opioid supply, according to a CNBC report.
- In a CDC study looking at patient records from 2006-2015, it was found that patients who previously had a pain diagnosis related to a chronic condition prior to initiating opioid treatment were more likely to develop long-term addiction.
- Commonly prescribed opioids exceed heroin as a cause of overdose deaths per 1,000, according to both the Center for Disease Control (CDC) Opioid Prescribing Data and a July 2017 report.
These are frightening figures, and employers should be thinking about how to address these trends. Many already are.
For example, 27% of employer respondents to the 2017 Willis Towers Watson Behavioral Health Pulse Survey indicated that they have an opioid management strategy in place as of 2016 with their pharmacy benefit manager (PBM). And if they didn’t, another 31% indicated plans for one in the following years.
Employers can do more to address the opioid issue and can start by asking some key questions to determine if there is opioid misuse or risk in their population.
Dive into the data
A first step is to consider a deep-dive analysis of the employee population data to identify evidence of opioid overuse and compare the data to benchmarks and year-over-year trends.
Consider asking the following questions:
- How many emergency room (ER) visits per 1,000 are specific to substance abuse?
- Are emergency room visits linked to opiate-seeking behavior? Are there more than five ER visits per member per year (PMPY) with an opiate prescription?
- What are PMPY substance abuse costs?
- How do our prescription rates and prescription dosage indicators, such as morphine equivalent dose (MME)/prescription compare to benchmarks? What percentage of claims exceeding 90 MME/prescription?
- What is the percentage of members filling opioids for less than three months versus those filling them for more than three months? Greater than three months should be marked as an additional red flag.
- How many of our members are at risk for long-term opioid use or addiction? This metric can be derived from PBM or medical plan predictive modeling capabilities.
Key questions to ask your carve out PBM partner
- What are you doing to manage pharmacy and opioids for your members? What about my population specifically?
- Are best practices being used to manage my members (e.g. requiring quantity limits on prescription fills, assigning members who are over-utilizing opioids (more than what would be expected as reasonable use for medical and health benefits) to lock in programs that restrict them to a designated provider/pharmacist for closer review and monitoring along with a mental health or substance abuse counselor oversight, and conducting pharmacy audits)?
- What processes do you have in place for managing specific conditions that require long-term pain management?
- What is being done to partner with providers to assist in pain management for long-term musculoskeletal conditions that require pain management, including fibromyalgia, neuropathy and post-operative pain management?
- How are you integrating with my medical plan partner(s)? Are you ensuring integration across all opioid management programs between the medical plan and PBM? (i.e. data and systems sharing)
Key questions to ask your health plan partner
- How is pain management incorporated into the care management program?
- Do care managers consistently assess pain and social determinants with engaged members?
- Are best practices being used to manage my members (e.g. reviewing in-network providers that require patients to sign pain contracts upon receiving prescription indicating acknowledgement of the risks and safety rules of taking opioids, lock-in programs (similar to PBMs), dose weaning to help members wean off of opioid medication, and replacement medications like Suboxone directed at opioid dependence paired with mental health/substance abuse counselor oversight)?
- Do health plans require their medical directors to contact providers when the member will not engage and there are red flags indicating opiate abuse?
Use your current state findings to develop a strategy
After assessing your current state of opioid risk and management, note the following approaches shown to help address and manage opioid use with members that will be further elaborated in the second part of this two-part blog series on developing a strategy to prevent opioid risk:
- Utilization management review and prior authorization requirements for opioid prescription fills/refills
- Steerage to cost and quality providers designated for an effective approach toward opioid management and mental health or substance abuse providers designated for substance abuse and opioid addiction treatment (medication assistance treatment (MAT))
- Predictive modeling and system flags to identify opioid risk and potential misuse
- Member-facing opioid education materials
Opioid misuse is a complex problem that requires a multifaceted approach to rein in. But employers that address risk in their population, ask the right questions to assess current programs and strategies in place and enlist the support of their stakeholders — including pharmacy benefit managers and health care plans — are positioned to play their part in helping address the opioid crisis and develop meaningful targeted strategies to prevent and manage opioid misuse in their population.