Grown-ups. Kids. Fathers. Mothers. Sisters. Brothers. The statistics are grim—the United States and Canada are the top two nations in the world in per capita consumption of prescription opioids, with more than 50,000 combined opioid-related deaths in a single year—but it’s important to remember the human element and to know that the opioid crisis affects individuals from all walks of life, writes Leila Mandlsohn, Pharm.D., in her article “Combatting the Opioid Crisis: Whose Responsibility Is It Anyway?,” from the January/February 2020 issue of Plans & Trusts.
Benefit providers—along with governments, nonprofits and health professionals—can play a vital role in the comprehensive approach needed to combat the opioid problem, writes Mandlsohn, a senior pharmacy strategy consultant with Green Shield Canada.
Seven Strategies for Benefit Providers
Following are seven strategies benefit providers should consider as they examine the role they can play in contributing to the solution.
1. Listing Decisions/Tiered Benefits
Cost cannot be the sole driver of which drugs to select for a plan, Mandlsohn writes. Plans should consider plan member safety and long-term risks when deciding whether or not to list more expensive nonopioid drugs as preferred alternatives over less expensive opioid drugs.
2. Drug Utilization Reviews and Morphine Equivalent Dose (MED)
“In simple terms, this is the process of identifying plan members whose drug usage exceeds an established utilization threshold and requiring additional clinical information before a claim payment is allowed,” Mandlsohn writes. She says it’s important for these reviews to be based on total opioid usage rather than dollars paid by the plan. A MED approach allows for better safety and access, calculating an individual’s total opioid use regardless of quantity, cost and potency of the products dispensed. Mandlsohn says MED-based drug utilization reviews should be implemented by every pharmacy benefit manager.
3. Abuse-Deterrent Formulations
These products use technology to discourage tampering and make it difficult to crush, chew or dissolve the pills, thereby acting as a deterrent to illicit use. Plans should consider restricting reimbursement to abuse-deterrent formulations when possible.
4. Long-Acting Formulations
Long-acting formulations carry a greater risk of overdose because they have a large amount of the drug in each tablet, Mandlsohn notes. A prior authorization process can limit access to patients who truly have a need for long-acting formulations—specifically, those who require continuous pain management.
5. Supply Limits for Both New Starts and Ongoing Prescriptions
Evidence suggests that a three- to seven-day supply is sufficient to manage most postoperative acute pain. Unused opioids following surgery represent wasted dollars to the plan and increased risk for nonmedical and experimental opioid use.
[Related Reading: Employers Face Unknowns of Opioids in the Workplace]
6. Digital Tools
Digital tools can help physicians and care teams monitor and manage pain in real time, allowing for safer and timelier pain management and interventions.
7. Care Pathways
Care pathways, which are established protocols for the forms of treatment patients will get, can ensure that patients receive access to high-quality, cost-effective treatment. Mandlsohn cites an example of providing access to nondrug treatments such as physiotherapy and chiropractic care to someone with lower back pain before allowing access to opioid drugs.
Striking the Right Balance: Benefits Providers and the Opioid Crisis
Benefit providers can play an important role in combating the opioid crisis by continually appraising available and emerging evidence, providing plan members with responsible access to both nondrug and drug treatment options, and having intervention programs in place to identify and support at-risk individuals. But it’s also important to remember that opioids play a legitimate role in patient care, particularly for those with acute pain, cancer-related pain and/or terminal illness, Mandlsohn writes.
“Bottom line: It’s a balance between adequate access to treatment and preventive strategies.”
Robbie Hartman, CEBS
Editor, Publications, for the International Foundation
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