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New Opioid Program Raises Concerns for Chronic Pain Patients

August 25, 2017
Express Scripts launches an Advanced Opioid Management Program intended to limit new opioid prescriptions to no more than a week of short-acting formulations, which all but ignores pain specialists discretion and individual patient needs.

With Snezana Mahon, PharmD and Jeffrey Fudin, PharmD

To help minimize early exposure and lessen overuse and abuse of opioids Express Scripts, a prescription plan provider, has announced a new program that will cap the length, dosage, and type of opioids prescribed to new users. As part of Advanced Opioid Management, new opioid users will be limited to short-acting opioids for no more than seven days.1

Value of opioid management program challenged by pain practitioners and chronic pain patients.

How Will the Advanced Opioid Management Program Work?

First-time opioid users will receive a letter regarding the safe use, handling, and disposal of opioids, explained Phil Blando, senior director of Corporate Communications at Express Scripts, in St Louis, Missouri. Should patient data indicate a cause for concern (for instance, if a patient fills two or more different short-acting opioid prescriptions within 30 days), a pharmacist with an opioid neuroscience specialty will contact the patient.

In addition, “we will provide deactivation disposal bags to first-time opioid utilizers who our data indicate are likely to have leftover medications,” said Mr. Blando. The bags will allow for convenient, at-home disposal of unneeded opioid pills.

“The program was created using Centers for Disease Control and Prevention (CDC) prescribing guidelines2 and was pilot-tested in our Lab,3” said Snezana Mahon, PharmD, vice president of product development for the company.

“It seeks to address overprescribing while also making sure those who rely on these medications have access to them without delay,” said Dr. Mahon. She added that patients would be able to get coverage for longer prescriptions, or long-acting opioids, through prior authorization requests.

Program Findings from the Pilot Study

In a study of more than 100,000 first time opioid prescription members, the intervention group received information on opioid use while the controls received the usual material provided by the pharmacy.3

Among patients in the intervention group, there was a 38 percent reduction in hospitalizations and 40 percent reduction in emergency room visits during the six-month follow-up period.3

The program, which will not apply to hospice, palliative care, or cancer patients, could have a major impact on prescribing practices. Currently, approximately 70% of new opioid prescribers receive prescriptions for more than seven days.2

Anticipating Limits on Prescription Opioids

Attempts to curb opioid prescribing often “inconvenience patients and doctors, increase copays, and perhaps even increase [patients’] desire to look for drugs from other sources, such as spouses, friends, or on the street,” Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP, president and director of scientific and clinical affairs at Remitigate, a company that provides software for clinicians, who was not involved with this program, told Practical Pain Management.

Theresa Mallick-Searle, MS, RN, ANP, a nurse practitioner at Stanford Healthcare Division of Pain Medicine in California went further in stating that efforts to limit opioids can prevent pain practitioners“ from prescribing what they feel is medically necessary,” and “will create anxiety, fear, and a possible under-treatment of pain in the long run.”

In her experience, those most affected by third-party efforts to reduce opioid prescriptions are “post-surgical and chronic pain patients who have been on chronic opioid therapy,” she told Practical Pain Management. Accordingly, programs like the one from Express Scripts could be particularly disruptive for patients receiving new opioid prescriptions following surgery.

“Most surgical patients may not return to see a provider after hospital discharge for 10-14 days, and are given insufficient medications to meet their analgesic needs prior to their first post-op visit,” said Ms. Mallick-Searle.

Better Yet, Give Pain Specialists More Discretion

If third party payers, including insurers and pharmacy benefit managers, were truly committed to fighting the opioid epidemic, Dr. Fudin said, “they would only cover abuse-deterrent extended-release opioids and short-acting opioids with abuse-deterrent properties,” rather than generics. 

A better approach for patients who require chronic opioid therapy would be for third-party payers to “require buprenorphine products that are FDA-approved as analgesics as first-line therapy,” said Dr. Fudin, “This is because there is a ceiling effect on CO2 accumulation with buprenorphine (compared to traditional full agonist opioids) because of its partial agonist/antagonist properties.”

“Unfortunately, most, if not all, third-party payers require failure on short-acting inexpensive generic formulations first,” Dr. Fudin told Practical Pain Management, “ and ‘failure’ in some cases means death. I have even seen a requirement to fail generic transdermal fentanyl in lieu of a buprenorphine patch—in my mind; this is a total disregard for patient safety in an effort to save money. 

“This is a complex issue,” Dr. Fudin said, “No matter what steps are taken—including increasing access to abuse-deterrent formulations—data clearly shows that as you narrow access to prescription opioids, you increase heroin use.”

To ensure that prescribers are able to treat pain patients appropriately while deterring opioid misuse, Ms. Mallick-Searle supporting prescriber education and practices “that anticipate the patient’s individual needs, and tailor the prescription(s) accordingly

Last updated on: August 30, 2017
Continue Reading:
A Plea for Proper Opioid Tapering
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