California is not immune to the opioid epidemic sweeping the nation. While the proportion of opioid-related deaths in the state sits lower than national averages, there are still thousands of opioid overdose deaths, emergency department visits related to overdose and tens of millions of opioid prescriptions every year.
San Francisco-based insurer Blue Shield of California launched its Narcotic Safety Initiative in 2015 with the goal of reducing opioid use among its members by 50 percent. Recently, the organization reported positive results that showed a 56 percent reduction in overall opioid use among members with chronic, non-cancer pain from 2014 levels.
“We know as pharmacists that there has been this pendulum swing in how prescribers are viewing the use of opioids as pain treatments,” said Salina Wong, Blue Shield of California’s director of clinical pharmacy programs.
“As we were identifying the risk that our members were carrying with opioid use we really felt that health plans have a major role in intervening and helping our providers prescribe more contentiously.”
The organization took a two-pronged approach to opioid use reduction: reducing the amount of people using chronically high levels of opioids and diverting people from getting on high levels opioids in the first place.
While Oxycontin is often identified as the “bad boy” of the opioid world, Wong said the overprescription problem goes far beyond that single example to medications like hydrocodone, which is often used to relieve low-level cough and cold symptoms. Another major priority was targeting extended-release opioids, which can lead to the build up of a physical tolerance and steadily increasing dosage.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Traditional methods of controlling nonprescription including changes coverage policies and formularies played a big role in the larger strategy to reduce prescriptions, which Wong said was based on a principal of “first do no harm.”
“For people that are already on high dosage you cannot and should not abruptly stop coverage because that could put them in a potentially risky situation,” Wong said. “We really focused our coverage policies on the new prescriptions to make sure they were prescribed for shorter periods of time and that doses were lower and tapered.”
Using the organization’s resources to combat issues with fraud, waste and abuse was also a major initiative.
Alongside this gradual decline in dosage and prescriptions was a correspondingly greater focus on patient support services like behavioral health treatments, CBT, as well as alternative non-opioid pain therapies.
Greater care coordination resources through Blue Shield case managers helped patients find pharmacies with non-opioid pain medications, manage coverage limits and connect them to behavioral health and recovery resources.
Key to that effort was driving awareness and clinician education about prudent practices aligned with the CDC guidelines for prescribing opioids. The health plan set up CME courses for providers to get insight into alternative pain treatments, opioid-use disorder and practical advice on how actually to taper and decrease dosage.
That included training and policies around the use of the CURES California Prescription Drug Monitoring Program, which helps to give providers visibility about whether others were involved in prescribing opioids to an individual patient. The use of CURES is currently mandated by state law, but Wong said Blue Shield was an early adopter of the technology.
Still, there is the open question of how these attempts to rein in opioid prescriptions could lead to unintended consequences for patients who may go without treatment or turn to illicit drugs as an alternative.
“We did try to asses that through our claims data by looking for hospitalization rates for overdoses and other symptoms of these unintended consequences. I don’t think we’re conclusive in what we’ve found, but if you look at the news anecdotally we’re still deep in this battle with things like illicit fentanyl,” Wong said.
“The primary message that I take comfort in is that a lot of people went down that path because they got their first prescription after a tooth extraction or surgery. This is about reaching people before they get so far down the road.”
Much of the training and education was focused on primary care providers as a way to give those clinicians the tools to better understand and handle specific issues related to opioid use and abuse in their daily practice.
“Because the opioid epidemic is so deep and so broad we can’t think that we can just refer to a specialist because there aren’t enough specialists to manage people at this point,” Wong said.
Like many other insurers, Blue Shield of California covers medication-assisted treatment (MAT) for opioid-use disorder, but Wong said the organization often ran into federal regulations which limited the ability to offer the MAT as an option. She added that a major overarching priority for those combating opioid use and abuse it addressing that issue.
“What we have to tackle as all stakeholders in this situation is expand the range of prescribers to prescribe MAT, including primary care.” Wong said. “Part of that is destigmatizing the use of MAT and the prescribing of MAT and the care of people with addiction.”
Photo: VladimirSorokin, Getty Images
