The opioid epidemic in the United States is a crippling crisis with devastating impacts on public health and economic welfare. According to the Centers for Disease Control and Prevention, in 2018, more than one in five people filled an opioid prescription, and 40 people died daily after taking prescription opioids.
Since the start of the pandemic, data shows a concerning spike in opioid mortality rates across the country, with 40 states reporting increases. With the heightened uncertainty brought on by a pandemic, patients are facing new emotional, financial and social stressors that contribute to a spike in opioid overdoses. The increased reports of opioid abuse and misuse can also be attributed to pandemic-related barriers to health care, such as limited access to treatment facilities, lack of coverage and high cost for non-opioid pain treatments, insufficient access to telehealth, and prolonged opioid dependency with postponed elective surgeries.
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For employers, the opioid epidemic leads to a ripple effect of economic and health concerns. While total costs from opioid abuse and misuse are estimated at $78.5 billion annually, a large, self-insured employer could spend an additional $14,810 for each covered employee who abuses opioids.
Finding a solution to this national crisis requires the commitment of every entity across the healthcare landscape. However, PBMs are uniquely positioned to help improve opioid prevention through programs that engage critical entities within the industry, such as prescribers and pharmacists. Employers can protect their members from the risks of opioid overutilization by leveraging a PBM partner with programs in place to improve health outcomes for their clients’ employees.
Here are three methods PBMs are using to curb opioid abuse and misuse, including effectively identifying high-risk individuals at the point-of-service, monitoring patient behavior to flag unsafe usage and aiming to change prescriber behavior through provider education.
Proactive Methods
One of the most effective ways to combat opioid abuse is to identify potential unsafe opioid use at the point-of-service and offer early interventions. Concurrent Drug Utilization Review (CDUR) programs accomplish early detection by checking the member’s prescription against any other active medications on file for potential conflicts and alerts pharmacies of potential opioid abuse.
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PBMs with tools to proactively analyze pharmacy claims information to reveal predictors of opioid overuse – such as if a member receives opioid prescriptions from multiple providers or uses multiple pharmacies to fill opioid prescriptions – can help identify and prevent addiction. By flagging these indicators, the pharmacist or prescriber can act on that information to reject prescriptions from being filled or alter the course of treatment for the patient.
Proactive programs designed to address opioid abuse include formulary management, which involves various utilization management strategies, such as prior authorization and initial dispense and quantity limits, to help ensure the appropriate use of prescribed opioids. Common formulary adjustments designed to prevent opioid fraud, waste and abuse include removing medications with extremely high-dose formulations, a great potential for abuse or misuse and high street values. By implementing these formulary changes, PBMs can support responsible prescribing that combats opioid overutilization.
Retrospective Methods
Another safety-focused solution is Retrospective Drug Utilization Review (RDUR) programs, where a PBM performs a retrospective claims review based on specific criteria to identify unsafe, inappropriate or ineffective patterns of medication use. RDUR programs reduce opioid-related fraud, misuse and abuse. This method can also reveal trends in prescribing, dispensing or administering drugs to inform targeted interventions and evidence-based decisions to help prescribers implement tailored treatment for the member at risk.
Once at-risk members are identified, PBM partners can create customized member profiles that strengthen a prescriber’s ability to intervene with patient counseling and additional support. Retrospective data analysis allows plan sponsors, PBMs and prescribers to better understand a patient’s specific pattern of medication use and facilitate improved patient-centric treatments and long-term recovery support.
Prescriber Education
In addition to improving health outcomes for patients through Drug Utilization Reviews, PBMs can drive lasting change within the prescribing community through educational intervention. By supplying prescribers with resources and evidence, PBMs have the ability to educate them on opportunities to decrease inappropriate opioid prescribing. For instance, PBMs can offer prescriber-specific reporting that details individual prescribing patterns and peer comparison reporting to inform them with the goal of shaping future prescribing habits.
PBMs can work directly with prescribers to inform clinical practice guidelines that promote the safe prescription of opioids, as well as support the prescribers’ understanding of the key drivers of opioid addiction within communities. For example, PBMs can educate prescribers on social determinants of health outside the healthcare system that may be impacting their community and can influence opioid overutilization. Social determinants, such as a patient’s income, environment and access to nutritious food or transportation, can influence opioid abuse and misuse. Identifying these factors is a critical touchpoint where PBMs can work with prescribers and communities to effectively care for patients at risk for or with a history of opioid addiction.
As we continue to learn more about what drives the epidemic and continually refine solutions to increase the effectiveness in curbing opioid misuse, PBMs need to evolve their programs to ensure patients have access to safer, more effective treatments.
The opioid epidemic is a public health crisis worsened by the pandemic, and PBMs have a responsibility to not only combat the key drivers of abuse and misuse, but also lead lasting change within the health care ecosystem. Combating the opioid epidemic requires partnership across all sectors of the industry, and PBMs are well-positioned to leverage connections across this network to make impactful change for their clients and their clients’ employees.
Photo: Moussa81, Getty Images
As Senior Director of population health programs and product development at Navitus Health Solutions, Julie Olson leads a team of pharmacists and product managers to design, implement and execute population health programs on behalf of Navitus and Lumicera Health Services. Her broad scope of responsibilities includes the development, management and outcome measurement of the product portfolio, predictive modeling, and ROI analysis. She has significant experience in Medicaid, Medicare Part D, and Star Ratings and frequently interacts with clients.
She holds a Doctorate of Nursing practice with a focus on health systems leadership and quality from Marquette University, a Master’s degree in community health nursing from University of Wisconsin-Madison, and two Bachelor degrees from University of Wisconsin-Eau Claire in nursing and psychology.
She has more than 27 years of diverse health care experience, including public health nursing, health outcomes research, public policy analysis and business development. She currently serves on the Wisconsin Nursing Association (WNA) Board of Directors and WNA COVID-Taskforce.
