Opioid Misuse Risk Management Strategies For Payers and PBMs

David Calabrese, RPh, MHP, Chief Pharmacy Officer at OptumRx, discussed how payers and PBMs can mitigate the risk and impact of the current opioid crisis in the United States, during his session at the PBMI 2018 National Conference.

He started his presentation by explaining that the opioid epidemic in the United States is a national health crisis. The United States represents on 5.4% of the world’s population, yet it consumes 80% of the world’s opioid supply. 

Mr Calabrese explained that every 16 minutes someone in the United States dies from an opioid related-cause and that 4.5 million Americans are estimated to have a substance use disorder related to opioid prescription painkillers. Additionally, the United States spends $504 billion annually on the opioid abuse epidemic—with these costs trending upwards based on the 21% increase in drug overdoes deaths reported in 2016.

He elaborated on the increase in overdose related deaths by citing data from the National Center for Health Statistics that showed deaths from illicit opioids, common prescription opioids, and a combination of the two, have all increase steadily since 2000. He explained that although national per capita opioid prescribing rates decreased between 2012 and 2015—deaths from illicit opioid spiked during this same time period, increasing by 134%. This suggests that lack of supply forced opioid abusers to turn to more dangerous street drug formulations like heroin and fentanyl.

Furthermore, Mr Calabrese highlighted that this trend is disturbing because 80% of illicit opioid drug users reported that they started out using prescription opioids. 

According to his presentation, opioid prescribing spiked in 2012 at 255 million annual prescriptions and 81.3 prescriptions per 100 persons. Since then there has been a 12% decrease in prescriptions per 100 persons and a reduction to 215 million prescriptions annually—as of 2016.

Opioid Risk Management

Mr Calabrese highlighted the development of UnitedHealth Group’s Enterprise Opiod Task Force, a group that leverages multidimensional assets to curb the trend in opioid misuse and improve outcomes. This task force combines data from across the health care spectrum to curb misuse, including pharmacy, behavioral health, care management, and more. 

Additionally, he highlighted the development of the OptumRx Opioid Risk Management strategy. This strategy begins with prevention and education, minimizes early exposure, reduces the inappropriate supply of opioids, treats at-risk and high-risk patient populations, and supports chronic populations and recovery. This multifaceted care approach delivers the right level of care to the right patients at the right time, in order to prevent and intervene in opioid misuse situations.

Prevention for at-risk opioid abuse members involves first-fill auto-generated patient mailings that include general opioid education. Members also receive numerous other educational resources via member portals and partnerships with national advocacy groups. Pharmacy and provider prevention education includes CDC guideline reinforcement, pain management resources, and chronic pain management reinforcement. Additionally, OptumRx’s prevention strategy includes resources for payers, including a risk management webtool, e-book, and clinical consultant guidance and support. 

Mr Calabrese stressed that it is crucial to manage supply because opioid dependence can start in just a few days. The risk of opioid dependence increases with each additional day supply added starting at the third day. He also noted that 30% of patients whose first exposure to opioid was a prescription lasting longer than 30 days will remain on opioids after 1 year. 

In order to minimize this risk, prescribers must be in line with CDC guidelines, Mr Calabrese said. These guidelines limited first-time prescriptions to a 7-day supply of a maximum if 49 morphine-equivalent mgs per day. Further, the CDC limited supplies to two 7-day fills in any 60-day period. They also require a prior authorization on all first-fill long-acting opioid prescriptions. 

According to Mr Calabrese, OptumRx’s program has made significant progress in getting prescribers in line with CDC guidelines. The national average of first-fill scripts not meeting CDC guidelines is 55%. However, OptumRx clients were 94.7% compliant in first-fill scripts having less than 50 morphine-equivalent mgs per day, and 95.2% compliant in first-fill scripts having less than or equal to a 7 day supply. 

OptumRx’s strategies have also resulted in an 18.6% reduction in total opioid prescription volume, a 14.4% reduction in morphine-equivalent doses across all opioid prescriptions, a 19.4% reduction in the average dose for first-fill users, and a 10.1% reduction in doses among experienced opioid users. 

Mr Calabrese concluded that all stakeholders must adopt strategies to reduce the risk of death cause by overprescribing of opioids. He noted that experts project that the opioid death toll could reach 250 deaths per day and result in more that 650,000 death within the next decade if interventions aren’t established.