The United States comprises approximately 4.4% of the global population but consumes 80% of opioids worldwide, and the majority of misuse comes from legally written prescriptions. In 2016, 116 people died daily from opioid-related overdoses, 2.1 million people had an opioid use disorder, and 11.5 million people misused prescription opioids. This epidemic has touched all areas of healthcare and requires many stakeholders to address it.
During a presentation at AMCP Annual Meeting 2018, Karen Cham, PharmD, CPHQ, Patricia Gray, PharmD, FCSHP, and Laura Morodomi, PharmD, all of Kaiser Permanente, discussed the opioid epidemic and described an opioid initiative that Kaiser Permanente developed.
Kaiser Permanente created a multifaceted approach to pain management, which involves safe and appropriate opioid use for non-cancer, non-palliative care, and non-hospice pain. Their integrated four-pronged collaborative approach includes patient education, physician education and support, community protection and outreach, and patient safety. “We realized we needed the support of all stakeholders to execute this initiative,” said Dr. Gray.
In 2010, they instituted a policy to reduce utilization of a brand-name drug when generics are available, as there is a high street value for brand-name opioids, and this initiative can reduce the risk of diversion. The program resulted in a reduction of tablets per 1,000 members per month between 2010 and 2015.
An estimated 0.3% to 0.7% of opioid purchasers participate in doctor-shopping, and the lock-in program can combat this. Lock-in involves improving care coordination between providers to decrease diversion and can include a single provider or pharmacy or both. There are limited data on outcomes of these programs, but unintended consequences can include an increased likelihood and frequency of people paying cash for controlled substances and constraints on patients with a legitimate need for these drugs.
To go along with this, an opioid utilization review can reduce the risk of patient harm, misuse, or abuse and can identify potential doctor- and pharmacy-shopping. Parameters for overuse (per Centers for Medicare & Medicaid Services’ requirements) include prescriptions for ≥90 morphine milligram equivalent (MME) dose and patients receiving opioids from four or more providers or pharmacies. With this program, a monthly report of potential “overutilizers” is sent to providers from the pharmacy for Medicare Part D beneficiaries; clinicians then review and provide action plans such as tapering medications, monitoring these patients, and providing referrals for addiction.
An integrated care plan that uses electronic medical records to document potential drug-seeking behavior, pain management care plans, and patient agreements can also be important to curb doctor shopping. Dr. Morodomi noted that with some of their implemented plans, data show that between 2011 and 2016, there was an approximately 40% decrease in opioid MME dispensed per member compared with an approximately 22% decrease in the overall United States (non-Kaiser Permanente members), per data from the Centers for Disease Control and Prevention.
The Kaiser opioid initiatives focus on alternative options for pain management, use a collaborative effort to address “red flags,” use data analytics to identify potentially at-risk patients, and communicate with the clinician to address more broadly, she concluded. “Better policy to improve patient care is very important. We need to rely on all of the available resources,” said Dr. Morodomi.
The future of opioid management may require pharmacy benefit managers to work with patients, providers, and pharmacists to increase the focus on preventing unintentional harm, providing non-opioid alternatives for pain management, and providing educational programs.
Presentation L2: Combating the Opioid Epidemic: Sharing Pharmacy Initiatives and Outcomes in an Integrated Healthcare System. AMCP Annual Meeting 2018.