Opioid Crisis, Our Response Massachusetts Coalition for the Prevention of Medical Errors. October 31, 2016

Transcription

1 Opioid Crisis, Our Response Massachusetts Coalition for the Prevention of Medical Errors October 31, 2016

2 Introduction: The Team Dr. Tony Dodek, Vice President, Medical Quality & Strategy, and Associate Chief Medical Officer Dr. Ken Duckworth, Medical Director, Behavioral Health Thomas Kowalski RPh, Director, Clinical Pharmacy Dr. Thomas Hawkins, Sr. Medical Director, Population Health & Analytics 2

3 The Toll Opioids Take on the Nation 259 million PRESCRIPTIONS FOR OPIOIDS WRITTEN IN Americans DIE EVERY DAY FROM PRESCRIPTION DRUG POISONING $53.4 billion ANNUAL COST OF NONMEDICAL USE OF OPIOIDS IN THE U.S. Source: CDC/NCHS, National Vital Statistics System America claims less than 5% of the world s population, yet it consumes roughly 80% of the world s opioid supply 3

4 Sources of Abused Prescription Drugs Friend/Relative-Stolen Drug Dealer/Stranger Friend/Relative-Purchase Doctor Prescription Friend/Relative-Free 4

5 Opioid Crisis, Our Response Prescription Pain Medication Safety Program

6 Our Population Data Approximately 11% of members with a pharmacy benefit filled a prescription 11% for a short-acting opioid 85% of these received one prescription for less than 30 days of treatment the average prescribed treatment duration was 7 days 15% of members received prescriptions for greater than 30 days, exposing them to the risks of addiction. 1% 28% 1% of members with a pharmacy benefit had a prescription for a long-acting opioid Approximately 15% of these had one prescription for less than 30 days the average prescribed treatment duration in this group was for 15 days It appears these members were being initially treated for acute pain with long-acting opioids, exacerbating their risks of falls and other accidents. 28% of members with Suboxone prescriptions were receiving these prescriptions from multiple prescribers, raising the possibility of fragmented care and possible medication misuse or abuse. 6

7 Prescription Pain Medication Safety Program: Objectives Program developed by an internal cross-functional team that included doctors, nurses, pharmacists and data analysts. This team convened an advisory group of network pain management, addiction experts, pharmacists and primary care providers to define best practices in opioid management to develop program with three key objectives: 1. Affordable, accessible and appropriate pain care 2. Reduced risk of member addiction 3. Reduced diversion of prescription drugs 7

8 Our Multipronged Approach Short-acting opioids require prior authorization after three 7-day** fills within 60 days of the original fill Long-acting opioids for new starts require prior approval Outlier reports for individual and group practices Internal cross-functional team review of outliers. Addictionologist on staff Buprenorphine and combination products limited to 16mg/day, prior approval required for greater doses Acetaminophen (APAP) 3g/day Rx limit* Block opioids from mail order *Changed to 4g/day at start of program **Changed 5/2013 to allow for multiple short-day supply fills, not to exceed two 15-days supply in 60 days, i.e. dentists 8

9 Prescription Pain Management Safety Program: Components Implement expert-defined elements of opioid prescribing best practices and monitor by requiring prior authorization A treatment plan with an exploration of treatment options Informed consent with a risk assessment for addiction signed by member An opioid agreement between the patient and prescriber outlining expected behavior of both parties Limited opioid prescribing group and the identification of a single pharmacy or pharmacy chain to be used for all opioid prescriptions 9

10 Short-Acting Opioids: New Starts Only Cancer Patients & Terminally Ill Excluded Up to a 7-day supply with initial prescription of short-acting opioids Additional 7-day supply within 60 days will be available, to a maximum of 30-day supply in a rolling 60-day period Additional prescriptions require prior authorization verifying existence of evidence-based opioid prescribing elements. If a prior authorization is not available at the point of sale, the member receives a 3-day supply of the short-acting opioid, allowing sufficient time for an authorization to be obtained. 10

11 Long-Acting Opioids: New Starts Only Cancer Patients & Terminally Ill Excluded Prior authorization of initial prescriptions for long-acting opioids; prior authorizations grant access to all long-acting opioids on BCBSMA formularies. Provider must document: 1. that the elements of evidence-based opioid prescribing were followed 2. a trial of short-acting opioids, or the reason one is inappropriate If a prior authorization is not available at the point of sale, the member receives a 3-day supply. This allows sufficient time for an authorization to be obtained. 11

12 Suboxone and Buprenorphine Prior authorization for treatment or maintenance of addiction Verification of the evidence-based elements of opioid prescribing and assessment of member s access to behavioral health support In addition, for Suboxone : Limit to MD prescribers with DEA waiver. All non-behavioral health services associated with the prescription are performed by the MD prescriber 16mg/day prescribing limit Coverage for pain excluded In addition, for Buprenorphine: Member must be pregnant or have an allergy to naloxone 12

13 Opioid Crisis, Our Response Program Results

14 Prescription Pain Medication Safety Program: Results Our campaign to improve quality of care and reduce the risk of addiction for members taking prescription painkillers had yielded significant results. Safety and quality UP Opioid prescriptions DOWN Addiction risk DOWN 14

15 Prescription Pain Medication Safety Program: Results Reduced the average monthly prescription rate of opioids like OxyContin by 15 percent Decreased the number of members using prescription opioids by 6 9 percent Wrote 14,000 fewer prescriptions for these drugs per month Eliminated an estimated 21.5 million doses of opioid-based medications in the community over a three year period Reduced claims for short-acting opioid painkillers such as Vicodin and Percocet by approximately 25 percent Reduced claims for long-acting opioids such as OxyContin by approximately 50 percent by switching patients to shortacting pain treatments Stopped 62,000 members from receiving inappropriate levels of acetaminophen Provided members who receive large amounts of narcotic medications with access to pain management experts and nonnarcotic methods of pain control Improved care coordination for members with painmanagement needs, especially for members with more than one provider-prescribed medication 15

16 Opioid Crisis, Our Response Strategies

17 Strategies Substance Use Case Management Partnerships with detox facilities Partnerships with local police departments Suboxone consulting by in-house board-certified addictionologist Serves as internal consultant to our case managers and utilization managers Serves as external consultant to our provider partners and members Removed pre-authorization requirements from ER to detox Improved access for members seeking detox, removing administrative barriers Increased support for methadone availability and affordability Removing prior authorization requirements Removing majority of member cost share Education and prevention Presentations to external audiences by addictionologist Participating in external forums 17

18 Vocabulary Incorrect Terminology Abuse or dependence (i.e. alcohol abuse, opioid dependence) Addict or abuser; words that end in ic (alcoholic, addict) creates an icky-feeling Addiction Clean or sober Clean/dirty urine Junkie/drunk/dope fiend/crackhead/pothead (all negative slang words) Frequent flyer Kicking Change To Substance use disorder; substance misuse Example: alcohol use disorder, opioid use disorder, opioid misuse Person with the disease of addiction; person struggling with substance use disorder Example: person with the disease of alcohol addiction, person struggling with opioid use disorder Disease In recovery; working towards recovery; working towards abstinence Positive or negative urine test and specify the substance Example: Positive urine test for opioids Person with the disease of addiction; person struggling with substance use disorder Example: person with the disease of alcohol addiction, person struggling with opioid use disorder Chronic relapsers Withdrawal Syndrome 18

19 Opioid Crisis, Our Response What s on your mind?