Health Plans Join Prescription Painkiller Abuse Battle

For the past decade, healthcare providers have been in the vanguard of efforts to combat the abuse and diversion of opioid pain medications such as Oxycontin. Now state and federal officials and health plans are joining the fray.

For the rest of his time on Earth, one of my best friends will be walking the fine line between the life-preserving benefits of opioid pain medication and addiction.

I call my friend The Mayor of Martha's Vineyard. For The Mayor, powerful pain medications have been a blessing since 2002, when both of his lower legs were shattered in a horrific car crash on the island. The driver, one of his best friends, died in the driver seat beside him.

"My body will never be the same, and I need surgeries every two years just to be functional," The Mayor told me this week. He has been "tapered off" all opioid medication this year, but knows he will go back on oxycodone or Percocet following a hip replacement procedure in the fall, another consequence of the deadly wreck.

The Mayor is resigned to his need for opioid medication and the necessity to take steps to avoid addiction. A pain management doctor has been working alongside his primary care physician for the past three years, and monthly urinalysis testing is part of the pain doc's deal.

"That's probably the best thing as part of their treatment program," he said of the urinalysis tests, which not only keep patients honest but also provide pain doctors with solid data to help manage medication dosage. "And most people will do [the urinalysis voluntarily]. They are not addicts. They're law-abiding citizens."

Blue Cross Blue Shield of Massachusetts started ramping up efforts to help avert the misuse of painkillers about two and half years ago. "A small number of our members were responsible for a high number of our prescriptions," Tony Dodek MD, the Blue's associate chief medical officer and VP of medical quality and strategy, told me this week. "Those same numbers were driving up our costs."

The payer decided to help members find a balance between getting opioid pain medication when warranted, while avoiding the danger of addiction. A new painkiller prescription policy that applies to all members except cancer patients and the terminally ill has posted "remarkable results," he said.

Under that policy, health plan members trigger a painkiller safeguard program after they reach a 30-day treatment threshold. A threshold is described as any number of prescriptions in a coverage year that add up to 30 days of treatment with an opioid pain medication. Once a member reaches the 30-day threshold, the health plan requires pain management safeguards such as a treatment plan and limiting members to obtaining painkiller prescriptions from one physician.

Dodek says the new prescription policy has generated two positive results over its first 18 months:

1. Prescriptions of narcotic pain medications fell by 6.6 million pills
2.  The company received only one member complaint.

"We had no disruption of pain medication for legitimate needs," he told me.

BCBS of Massachusetts' prescription policy also requires physicians to start pain medication prescriptions with short-acting formulations, which are generally less addictive than long-acting drugs. The policy shift, which applies to all members except cancer patients and the terminally ill, has resulted in a 50 percent reduction in prescriptions for long-acting painkillers, Dodek says.

And the health plan sends monthly letters to physicians about members who may be "pill shopping" for pain medication from several doctors simultaneously. "We see that in our claims pretty quickly," he told me, noting prescription claims are processed in real-time.

Another payer, Aetna, has launched "active surveillance" efforts on its members to help ensure that pain medications are not abused or diverted, Edmund Pezalla MD, MPH, the company's national medical director for pharmaceutical policy and strategy, told me this week. "We're looking for those [members] who have been getting a lot of narcotics at higher doses," he said. "We have a pharmacist who looks at this."

Pezalla says Aetna, which has 22.7 million medical insurance policy members and more than 600,000 physicians in the company's healthcare networks, reaches out to patients when painkiller abuse or diversion is suspected. "We offer patients counseling. We try to get to the patients, and assume they are people who need help." He notes that the health plan covers substance abuse treatment programs and can restrict a member's access to painkillers. "We can limit them to a single pharmacy or a single doctor."

While acknowledging that any snooping in members' claims data raises privacy concerns, Pezalla says health plans bear a responsibility for patient safety in the area of prescription medication.

"Safeguarding the privacy of our membership is very important to us," he told me. "But under HIPPA and other laws and rules, we can track anything that is part of the payment system or normal care."

Pezalla says Aetna is generally supportive of public policy efforts to address the abuse and diversion of painkillers, including state-based registries that track prescriptions of narcotic medications. "If a state puts a registry together, we will help them. We are here to help where we can," he told me. "The improper use of medication just makes it harder for the patients who need it."

Governors Take a Stand
In January, Vermont Gov. Peter Shumlin (D) devoted his entire state of the state address to the Green State's drug addiction crisis. In March, Massachusetts Gov. Deval Patrick declared an opioid abuse public health emergency in the Bay State.

"We have an epidemic of opiate abuse in Massachusetts, so we will treat it like the public health crisis it is," Patrick said in a prepared statement. His office announced a range of measures designed to combat the problem, including mandatory physician and pharmacist use of the state's narcotics prescription registry.

Background facts provided in the statement paint a dire picture of opioid abuse: "The use of oxycodone and other narcotic painkillers, often as a route to heroin addiction, has been on the rise for the last few years in Massachusetts. At least 140 people have died from suspected heroin overdoses in communities across the Commonwealth in the last several months, levels previously unseen. From 2000 to 2012, the number of unintentional opiate overdoses increased by 90 percent."

In April Patrick went so far as to order a ban on a new painkiller, Zohydro, until officials can "safeguard against the potential for diversion, overdose and misuse." Zohydro is a long-acting form of hydrocodone. (Vicodin is a short-acting form of the drug.) Federal and state officials, including Sens. Mitch McConnell (R-KY), Lamar Alexander (R-TN) and Tom Coburn (R-OK) and 29 attorneys general, are urging the FDA to reconsider its approval of Zohydro. The drug's maker says it is working to develop an abuse-resistant formulation of the drug.

Meanwhile, the Mayor of Martha's Vineyard hopes his governor can walk the fine line between cracking down on the minority of patients who abuse or divert painkillers, and the majority of patients who need pain medication to cope with arduous suffering.

"The percentage of people who take these drugs and abuse them is miniscule compared to people getting good treatment," The Mayor told me, adding a backlash against painkiller prescriptions is already having a chilling effect in the medical community. "They're just afraid for their jobs."