The Balancing Act of Using Pharmacy Strategies to Fight the Opioid Epidemic

Utilization management tools and formulary designs are components of a multifaceted strategy to curb opioid overdose death rates, but they must be applied in a flexible manner, according to speakers at the Academy of Managed Care Pharmacy (AMCP) annual meeting.

Bonnie C. Greenwood, PharmD, BCPS, clinical program director at University of Massachusetts Medical School, acknowledged that she could not give a perfect set of answers to solve the opioid crisis, but said she would share insights about what has worked for payers and managed care organizations as some of the tools in their toolbox.

She discussed a 4-pronged framework for managed care pharmacy strategies related to opioids: (1) establishing goals for safe prescribing and appropriate pain management; (2) expanding patient access to coordinated pain management and substance use disorder (SUD) treatment; (3) developing systems approaches to changing prescriber behavior; and (4) enhancing provider tools for screening, monitoring, and mitigating the risks of opioid therapy.

The safe prescribing goals are the foundation of the CDC’s guidelines for opioid prescribing, which have seen widespread uptake across the healthcare system but sparked concerns in the medical community over inappropriate applications, like the use of blanket dosage limits and other mandatory policies.

“This is not the first time the managed care pharmacy or payer community has heard the criticism of a one-size-fits-all approach when we’re trying to implement population-level change,” Greenwood said.

In terms of expanding patient access to pain management, she spoke of the importance of steering patients toward alternatives like nonopioid or nonpharmacological options. Step therapy, for instance, is an area of opportunity where payers can drive safer treatment courses by encouraging tactics like physical therapy instead of medication use for certain types of pain. However, the issue of “siloing” between pharmacy and medical benefits for these alternative treatments poses a challenge.

The systems approaches within the framework are where payers can employ traditional utilization management tools, often implementing many tools simultaneously. For instance, MassHealth, which is Massachusetts’ Medicaid program, requires prior authorization for high-dose opioid prescriptions and overlapping prescriptions. By imposing 3 sequential high-dose limits over a 15-year period, the average daily dose of opioids decreased after each step, the percentage of patients exceeding the limits decreased over time, and the greatest impact was seen in patients who used the highest doses. Importantly, this strategy allowed for multidisciplinary experts to discuss outliers and identify cases that should be exempt from the rules.

“We don’t have evidence that says this is exactly the right way,” Greenwood said. “…What’s very important here is that any time you are implementing a tool such as this, that it’s informed by the evidence.” This evidence can come from national literature or from looking at a plan’s own data, she added.

Joining Greenwood to discuss the fourth component of the framework was Kimberly Lenz, PharmD, clinical pharmacy manager, of MassHealth/Office of Clinical Affairs and University of Massachusetts Medical School. When looking to monitor and mitigate the risks of opioids, patient review and restriction programs can help drive safer utilization by “locking in” patients to one specific provider or pharmacy, Lenz said. Additionally, giving managed care organizations access to the state prescription drug monitoring program (PDMP) can be beneficial to both member and payer if it results in better coordination of care.

Another area of risk mitigation is in encouraging access to and use of naloxone to reverse overdoses. With more than 26,500 overdoses reversed just by laypeople between 1996 and 2014, naloxone is the only intervention that has demonstrated a direct link with opioid mortality, Lenz said. Advocacy efforts have increased access, and more and more states have statewide standing orders or pharmacist prescribing of naloxone. Some states include naloxone prescriptions within their PDMPs, but “we need to make sure that if it is incorporated, that we’re using it appropriately, and not penalizing patients for having that on their profile,” she warned.

Lenz provided several examples of state and local initiatives that have applied harm reduction theories to the use of naloxone to prevent overdose deaths. For instance, in the Prevention Point Pittsburgh program, all patients presenting to a pharmacy with an opioid prescription are counseled on overdose risk and offered naloxone. The Massachusetts Overdose Education and Naloxone Distribution program has partnered with needle exchange programs in 19 communities that have each seen reduced overdose deaths without increased opioid use. This program’s results were among the first to disprove the myth that harm reduction strategies drive opioid use, Lenz said.

According to Lenz, there are several harm reduction strategies that have shown promise internationally but have yet to be piloted in the United States, such as supervised injection sites and fentanyl testing strips. A pilot of the test strips in Vancouver found that 86% of heroin tested positive for fentanyl. While getting a positive result from these strips may not stop someone from using the drug, it can at least allow them to take the drug around someone who is able to rescue them with naloxone in case of an overdose.

Lenz sees the harm reduction strategies as holding more promise for preventing deaths than efforts to curb prescribing through PDMPs or drug rescheduling, which may actually push people to seek illicit substances if they can no longer obtain a prescription opioid.

Based on surveys conducted by the Addiction Advisory Group established by AMCP, recommendations for payers included removing barriers to timely naloxone access, encouraging continuity of care, and increasing awareness of and access to medication-assisted treatment. “Look at your policies, procedures, and benefit structure and ensure that you are actually reflecting substance use disorder as the chronic disease that we now know it is,” Lenz suggested.

Lenz also noted that about half of survey respondents said that bias and stigma affect payer coverage of SUD treatment, and most respondents’ plans are encouraging instead of requiring naloxone coprescribing with high-risk opioid prescriptions.

Because none of these tools will work universally, Lenz recommended that the audience should “go back and evaluate your strategies and ensure that you’re providing comprehensive strategies for patients, making sure that whatever strategy you use has the leeway to be flexible around their needs.”

These strategies should be tweaked as needed to ensure “that you’re providing the right balance of access to treatment for pain” against the risk of addiction, Lenz concluded.