Contributing Voices

Changing the Standard of Care: Treating the Controlled Substance Crisis

Jonathan Gavras, MD
Chief Medical Officer, Prime Therapeutics

Our country is in crisis. We have an epidemic on our hands that crosses geographic boundaries, socio-economic status, gender, and many other categories. According to the American Society of Addiction Medicine, drug overdoses kill nearly 50,000 Americans each year. The media is certainly putting a microscope on it. Legislators are acting on it. Every stakeholder in the medical delivery chain is analyzing it–and I encourage physicians and other prescribers to take a look at their role in the problem.

Of Prime Therapeutics’ 22 million members, more than 2.4 million commercial members had a claim for one or more controlled substance over a three month period of time—including opioids (e.g., Percocet, Vicodin), sedatives (e.g., Xanax), insomnia drugs (e.g., Ambien), stimulants found in ADHD drugs, and muscle relaxants. All of these drugs have the capacity to be fatal if they are abused—especially if they are used together.

As an internal medicine physician and pulmonologist by training, I’ve seen firsthand how the treatment of pain has evolved. Standard of care changed significantly in the early 1990s when the treatment of chronic pain was brought to light. The prescribing community was taught to take steps to manage pain with appropriate controlled therapy as if it was the “fifth vital sign.” Many key stakeholders in American health care contributed to this change.

Fast forward more than 20 years and we are now seeing the deadly effects of that change. The pendulum has swung too far in the direction of prescribing opioids. Instead of using these medications in an appropriate manner for short-term pain management, prescribers are using them to treat long-term and chronic pain

As a pharmacy benefits manager, Prime has a responsibility to our health plan clients and their members to change the growing use and misuse of these drugs. Ten years ago, Prime began noticing a problem. Our health outcome researchers developed a “controlled substance score” that counts for how many controlled substances a member is taking, how many prescribers and pharmacies that individual is using, and if there is evidence of increased controlled substance use. The output of that equation helps us identify and help people who may be at risk for an overdose; the higher the score, the higher risk that an individual will use the emergency room or be hospitalized.

We have shared our scoring system publicly through the Academy of Managed Care Pharmacy and other channels, and we encourage other organizations to use this scoring system to reduce risks for overdose.

Our programs have shown that utilization and costs related to controlled substances decrease with an intervention. For example, we have partnered with one of our health plan clients to alert prescribers of their patients who met the controlled substance score criteria of “high risk.” The communication was effective in reducing the number of prescriptions written and associated costs, and ultimately reduced members’ controlled substance scores. Nearly two thirds of physicians said the letters were very useful and one third indicated they planned to discontinue or modify drug regimens.

Leveraging data and communicating with those directly involved in this epidemic has proven to be effective at changing behaviors related to controlled substance abuse. But more needs to be done—and quickly.

Prime supports programs and action that protects those most at risk, including comprehensive usage of prescription drug monitoring programs and co-prescribing abuse deterrent medicine for those most at risk of overdose. An important next step is changing the standard of care to follow the new CDC guidelines for prescribing controlled to dramatically lower the risk of overdose in our society.

Jonathan Gavras, MD, is chief medical officer at Prime Therapeutics, a pharmacy benefits manager owned by 13 Blue Cross and Blue Shield Plans, subsidiaries, or affiliates of those plans.