Opioid Prescriptions Decreases After Major Insurer Changes Its Opioid Prescription Policy
Interview with Macarena C. García, DrPH, and Pamela Flood, MD
On July 1, 2012, Blue Cross Blue Shield of Massachusetts (BCBSMA)—the largest insurer in the state with approximately 2.8 million members—changed its opioid prescription policy. To see whether this policy affected prescription opioid use, the Center for Disease Control and Prevention (CDC) analyzed BCBSMA prescription claims data from July 2011 to June 2015. The study found that both opioid prescribing rates and the proportion of BCBSMA members using opioids declined after the new policy was implemented.1
These results suggest that BCBSMA’s new policy reduced the use of prescription opioids among its members and that other insurers, both public and private, could similarly reduce the risk of opioid dependence and abuse yet ensure accessible pain care by developing their own best practices for prescription opioid use. To aid the development of insurer opioid utilization programs and policies, in March 2016 the CDC released a comprehensive list of recommendations, the CDC Guideline for Prescribing Opioids for Chronic Pain.2
“After BCBSMA implemented a new opioid utilization program, there was a significant decrease in both the number of opioid prescriptions among its members as well as a reduction in the percentage of members with a current prescription for opioids,” said lead author Macarena C. García, DrPH, of the CDC. “The implication is that evidence-based utilization management practices can promote best practices in opioid prescribing, while reducing the risks associated with these medications. Specifically, the program encourages prescribers to use opioids more judiciously in the treatment of conditions characterized by time-limited, acute pain.”
The 2016 CDC Guidelines “provides important guidance intended to stem the adverse consequences of inappropriate opiate prescribing,” commented Pamela Flood, MD, of the Stanford University Medical Center, who was not associated with the study. The authors “provide an analysis of the impact of similar changes that were put into place by a single large insurer in 2012 in Massachusetts. To the extent that the reduction in opiate prescription resulted from the changes made, their findings are encouraging. However, reduction in opiate prescription is only a surrogate endpoint. It would be more encouraging if associated changes in opiate overdose-related death were identified,” noted Dr. Flood
“Furthermore, the authors mention correctly that observational studies cannot demonstrate causality. We cannot be sure to what extent the policy change caused the reduction in opiate prescription compared to other factors such as publicity about the ‘opiate epidemic.’ A parallel analysis on prescription rates using another large insurance dataset such as Medicaid that did not make the same policy change but would be subject to similar societal forces would shed light on these issues,” she said.
Study Results Examined
The new study found that during the first 3 years after the new policy was implemented, the average monthly prescribing rate for opioids decreased 14.7%, from 34 per 1000 members pre-implementation to 29 per 1000 members post-implementation.1 While the average monthly prescribing rate for long-acting opioids (eg, extended-release formulations, acetaminophen/oxycodone, transdermal buprenorphine, hydrocodone) remained constant (3 per 1000 members) before and after program implementation, the averagely monthly prescribing rate for short-acting opioids (eg, acetaminophen/caffeine/dihydrocodeine, acetaminophen/codeine) decreased 16.1% from 31 to 26 per 1000 members. The authors noted that this was probably due to improved education among prescribers and the need for prior authorization for prescriptions of longer than 30 days.
In addition, the monthly percentage of members with current opioid prescriptions declined from 2.58% pre-implementation to 2.24%. The percentage of members with long-acting prescriptions decreased 16.1%, from 0.24% of members pre-implementation to 0.22% post-implementation. The percentage of members with short-acting opioid prescriptions decreased 12.9%, from 2.49% to 2.17%.
In general, there was an annual decline of 6% to 9% in the percentage of members on short-acting and long-acting prescriptions and in opioid prescribing rates post-implementation compared to the pre-implementation period. The first 3 years post-implementation saw approximately 21 million fewer opioid doses compared to pre-implementation.
The study authors noted that other factors such as media coverage of opioids and increased use of the prescription monitoring program could have contributed to the decline in prescription opioid use.
New Program Designed Around Expert-Defined Best Practices
BCBSMA noted that its program was developed collaboratively among a variety of stakeholders, including physicians, nurses, pharmacists, actuaries, lawyers, data analysts, medical societies, medical and pharmacy boards, the patient advocacy group Massachusetts Pain Initiative, and the top 10 opioid-dispensing pharmacies in Massachusetts. The program was designed around expert-defined best practices for opioid prescribing that included formal agreements between patient and provider; a requirement for BCBSMA approval before dispensing new opioid prescriptions; and quantity limits.
Program elements include: