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Opioid Prescriptions Decreases After Major Insurer Changes Its Opioid Prescription Policy

November 15, 2016
Targeting high opioid prescribing rates and the associated abuse of these drugs is key to addressing the current opioid epidemic. But what is a viable solution that will allow patients to have access to the pain medications they need?

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.

Establishing guidelines for proper prescribing of short-acting opioids has stemmed the flow of prescription in Massachusetts.

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:

  • Providers conducting a risk assessment for abuse that the patient must sign
  • Providers and patients developing a treatment plan that considers options other than prescription opioids
  • A formal agreement between patient and prescriber outlining behavior expected of both parties, if opioids are prescribed
  • Assigning the patient to a single pharmacy to dispense all opioids if opioid misuse is suspected or when coordination of care among multiple providers is indicated
  • Requiring prior authorization by BCBSMA for new short-acting opioid prescriptions with more than a 30-day supply (except for oncology patients or terminally ill patients)
  • Requiring prior authorization by BCBSMA for all new long-acting opioid prescriptions (except for oncology patients or terminally ill patients)
  • No longer permitting pharmacy mail orders for prescription opioids
  • Referring all patients with chronic pain to case management, who advise them on nonopioid therapies
  • Covering all BCBSMA members for physical therapy, pain management, addiction treatment, chiropractic services, and cognitive behavioral therapy

The study authors suggested that the prior authorization requirement for new short-acting opioids prescribed for more than 30 days prompted providers to evaluate the medical need to initiate opioids for extended periods and to assess concomitant risks. The decline in opioid use was highest for short-acting opioids, which account for the majority of opioid prescriptions. However, the authors noted, these data did not assess whether limiting access to opioid prescriptions affected patient pain and function.

Improving opioid prescribing practices is one of the 3 priority areas of the US Department of Health and Human Services’ initiative to address the opioid epidemic in the United States.3 Results from a recent microsurvey by InCrowd, a polling, supports the appropriateness of targeting opioid prescription practices. In the survey of 225 providers (primary care physicians, emergency department physicians, and pain management specialists), physicians overprescribing opioids for pain management was the most commonly cited factor underlying the increased misuse of opioids by patients, topping the list at 30%.4 The majority of survey respondents wanted additional limitations on opioid pain prescriptions.4 BCBSMA’s opioid utilization program offers a roadmap for implementing new policies that promote best practices in prescribing opioids.


Last updated on: March 16, 2017
Continue Reading:
AMA Survey Finds Doctors Widely Support Prescription Drug Monitoring Programs

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