Larry Beresford

There was a whole world of hurt out there in the mid-’90s. Chronic pain—the kind of pain that lasts for months and interferes with daily functioning—wasn’t being treated very well. Pain was underrated as a health problem. Physicians were justifiably concerned about patients becoming addicted. A defensive mindset might have been part of the problem: Physicians and hospitals didn’t want survivors to sue them for giving loved ones too much medicine.

Then some pharmaceutical companies started promoting new opioid formulations for chronic pain conditions. Critics say their marketing grossly downplayed the dangers of opioids while overselling their benefits, and lawsuits against some of the companies are wending their way through the courts.

Now we are in what the CDC is calling, with ample justification, an epidemic of deadly prescription drug overdoses, many of them from opioid medications, a group that includes hydrocodone, oxycodone, oxymorphone, and methadone.

“Where we once had one public health crisis—unrelieved pain—now we have two,” says pain expert Steven D. Passik, PhD, vice president of clinical research and advocacy at Millennium Health Institute, a personalized medication intelligence solutions company in San Diego.

At what cost pain relief?

Pain is usually transitory, but chronic pain is now recognized as a real phenomenon. Often there is an initial provocation—a wrenched back, for example—and the pain persists after it is over. Other times there is an underlying cause like cancer or arthritis that regularly “feeds” the pain. But sometimes there is no discernible reason for the pain but it continues anyway. A 2011 Institute of Medicine report estimated that 100 million Americans suffer from chronic pain, and that the direct costs for medical treatment and indirect costs from lost productivity add up to over $600 billion each year.

Meanwhile, the Coalition Against Insurance Fraud, a group that includes insurers, government regulators, and consumer groups, estimates opioid abuse costs over $70 billion each year.

The death toll from opioid abuse is enormous. In 2012, the last year for which data are available, 16,007 (39%) of the 41,502 American deaths from drug overdoses were from opioids. Consumption of opioids quadrupled between 1999 and 2012, and the age-adjusted death rate from overdoses tripled during that period.

Age-adjusted drug-poisoning death rates: United States, 1999–2012

Deaths per 100,000 population

Source: CDC

Making matters worse, opioids are often prescribed in dangerous combinations with other medications. In a report titled Nation in Pain issued late last year, Express Scripts, the country’s largest PBM, estimated that almost 60% of Americans taking opioids on a long-term basis had a prescription for another drug that could be dangerous when taken with an opioid medication (the company arrived at national estimates by extrapolating from its claims data).

Express Scripts’s data also shows that once someone starts taking opioids on a long-term basis, there is a good chance that they will continue to do so for years. According to the PBM, nearly half (46.9%) of the new opioid users who take the pain medication for more than 30 days during the first year of use continue to take them for three years or longer. What’s more, roughly half of those long-term users are taking short-acting opioids, which may make them even more susceptible to addiction.

Some states have more painkiller prescriptions per person than others

Number of painkiller prescriptions per 100 people

Source: CDC

There are some bright spots in this otherwise grim picture. The rate of increase in opioid overdoses has notably slowed in recent years; in fact, the number of deaths from opioid overdose declined by 5% from 2011 to 2012. Many states have implemented polices that require providers to check databases of prescriptions for controlled substances before they prescribe certain medications. The checks are supposed to make them aware of patients who might be abusing opioids and other potentially dangerous medications. Last year, over the objections of pharmacist groups, the federal Drug Enforcement Agency (DEA) moved all hydrocodone drugs from Schedule III to the more restrictive Schedule II, which, among other things, means prescriptions for hydrocodone products can’t be phoned in.

Health plan efforts

Most of the blame for the opioid abuse epidemic has been directed at the companies that make and market the drugs. But private and government payers have also been criticized for, at the very least, not doing enough to stop it. Stingy coverage of a more integrated approach to chronic pain management means doctors are more apt to depend on opioid prescriptions, say the critics. There’s also been some finger pointing at formularies that put tamper-resistant opioids on more expensive tiers and impede access to the buprenorphine–naloxone combination (Suboxone) used to treat opioid addiction. The GAO and Pro Publica, the not-for-profit investigative journalism organization, have published reports critical of the CMS and its Medicare Part D program for allowing dangerous prescribing practices, including excessive prescription of opioids.

But if you are part of the problem, you can also be part of the solution, and health plans have been taking steps to rein in rampant opioid prescribing. For instance, Aetna implemented a misuse, waste, and abuse program involving clinical pharmacists, care managers, and behavioral health clinicians. The program coordinates efforts across departments to encourage safe prescribing, identify members at risk, and provide appropriate support to fight addiction.

“When an opioid pharmacy claim overlaps with a buprenorphine pharmacy claim, we notify the prescriber within 48 to 72 hours by fax,” explains Celynda Tadlock, PharmD, vice president of Aetna Pharmacy Management. “An Aetna pharmacist then calls the provider three days following the fax notification. Ultimately, we want the provider to contact the member to stop continued opioid use.”

Anthem identifies members who have filled 10 or more prescriptions for controlled substances within a three-month period. (Members with cancer or multiple sclerosis are excluded.) Over 61% of the members identified had a reduction in the number of opioids after the intervention.

CeltiCare Health Plan in Massachusetts looks at providers’ prescribing practices and the percentage of their prescriptions that are controlled substances. Outliers are flagged for educational outreach, typically starting with a letter or phone call sharing the data that compares their prescribing practices to those of their peers.

“We can and do refer them to our behavioral component for face-to-face education,” says Robert LoNigro, MD, CeltiCare’s chief medical officer. Of course, physicians are given a chance to explain their prescribing patterns. CeltiCare is exploring additional programs, including a hot line for providers to obtain real-time information about opioid prescribing and risk-modeling tools to help them identify which of their patients might be at a higher risk for misusing opioid medications.

Blue Cross and Blue Shield of Massachusetts spotted a problem in its claims data about three years ago when it became clear that a small percentage of its members were being prescribed a disproportionate share of opioid analgesics, says Tony Dodek, MD, the plan’s associate chief medical officer. The insurer introduced a program—developed with an outside panel of physicians, pain experts, and addiction specialists—to reduce the volume of opioid prescribing while protecting those members with legitimate treatment needs. Steps include limiting the supply of short-acting opioid analgesics to two 15-day periods over two months (with some well-defined exceptions) and requiring providers who prescribe long-acting opioids to start with short-acting medications. Dodek says his company also began sending prescribers reports that list their patients for whom they have prescribed opioids. During the first 18 months of this effort, called the Prescription Pain Medication Safety Program, prescriptions for short-acting opioids fell by 20%, and prescriptions for long-acting ones fell by 50%.

Health insurers who document how they deal with the opioid abuse problem are performing an important public service, says Tamara M. Haegerich, PhD, of the National Center for Injury Prevention and Control. “We looked at the whole body of literature, and I think it’s important to note that there’s a lot we don’t know about the effectiveness of these programs,” she tells Managed Care. “When health plans use these techniques, it’s important to gather and publish data on them. Improving the evidence base is critical, and health plans have a vested interest in using and evaluating these techniques.”

CVS identifies outliers

PBMs and the national drugstore chains are also talking up their efforts to quell opioid abuse. For example, on its website Express Scripts describes a program designed to limit opioid abuse among those getting prescriptions through worker compensation. When an injured worker presents a prescription at the pharmacy, the company’s claims processing system calculates its morphine equivalent dose (MED). If the prescription dose is over certain MED limits, it is submitted to the payer for a special review and the prescribing physician is sent a reminder about the guidelines for prescribing opioids. The company also uses a pharmacy “lock in” program for some claimants. Their prescriptions for drugs likely to be abused can be filled at just one pharmacy and sometimes the script can be written by just one prescriber.

Two years ago, CVS Health executives announced in the pages of the New England Journal of Medicine that the company had identified physicians with unusual patterns of prescribing high-risk drugs (alprazolam, a benzodiazepine, and carisoprodol, a muscle relaxant, as well as hydrocodone, oxycodone, and methadone) by combing through its huge cache of claims data. The company discovered 42 outliers and banned 36 from fulfilling prescriptions at their stores.

But the DEA has gone after CVS—and its rival, Walgreens—as part of a crackdown on prescription drug abuse. Last month, CVS agreed to pay a $22 million settlement after a DEA investigation found that employees at two of its pharmacies in Sanford, Fla., dispensed controlled substances without legitimate prescriptions. In 2013, Walgreens reached an $80 million settlement after the DEA found problems with record keeping and prescribing practices at a distribution center and six of its retail outlets in Florida.

What else can be done?

Although CVS and Express Scripts have databases that are useful in limiting opioid prescriptions and can be shared with payers, the state-run prescription drug monitoring programs (PDMPs) and their databases have been largely off limit to private payers. Experts have called for allowing insurers more access to PDMP information.

Andrew Kolodny, MD, praises payers who are getting involved in fighting the opioid abuse epidemic. Kolodny, the chief medical officer of Phoenix House, a New York City drug and alcohol rehabilitation program, and president of Physicians for Responsible Opioid Prescribing, calls Blue Cross and Blue Shield of Massachusetts’s program “very smart.” It is important, he says, for payers to work on reducing the number of Americans starting opioid therapy for chronic pain because once they are on it, stopping is often difficult. Kolodny spreads blame for the opioid addiction epidemic around: “The FDA has been awful on this issue,” and he mentions a “well-financed misinformation campaign” by pharmaceutical companies. But he would also like to see state medical boards and the medical community get more involved. Tamper-resistance opioids might be helpful but because most people get addicted to the oral formulations he expects them to make “only a very small dent in this problem.” It comes down to this for Kolodny: “Opioids are lousy drugs for most people with chronic pain,” and we have to come up with better ways for helping people suffering with pain that won’t go away.

Larry Beresford is a freelance medical writer in Alameda, Calif.