Studies Review Methods of Alerting to Potential Opioid Overuse

Since the year 2000, overdose deaths have risen 137%, with a 200% increase in deaths related to opioid misuse. At the AMCP Managed Care & Specialty Pharmacy Annual Meeting, Prime Therapeutics presented 2 opioid studies: one evaluated the association between opioid misuse and healthcare utilization and cost of care; and the second evaluated a new program to flag potential opioid misuse earlier than the program in use by CMS.

The first study examined how concurrent use of opioids, benzodiazepines, and muscle relaxants, known as “triple threat” drugs, affect healthcare utilization. The study reviewed 15 million members across 13 health plans. They had to be enrolled for 2 consecutive years and have a minimum of 1 day of triple threat overlap.

The results showed that members with overlap had higher rates of visits to the emergency department (ED) and higher healthcare costs. In 2014, members with 31-90 days of consecutive triple threat usage had 1.1 greater odds of an ED visit; members with 91 or more days had 1.14 greater odds. Members with 21 or more days had 1.07 greater odds of higher total cost; members with 91 or more days had 1.13 greater odds. Those with 31 or more days had an annual mean per member adjusted total cost of $3175.

The second study involved a new concurrent drug utilization review (DUR) edit delivering point-of-sale alerts to pharmacists of potential opioid misuse. The program provided a warning about the claim, but would not reject the claim from payment, and would identify potential opioid misuse earlier than the current overutilization monitoring system (OMS) from CMS. Those who were flagged by both the DUR edit and the OMS were enrolled in case management, if necessary. Member behavior was also examined after the new program in order to determine its impact.

The program was enacted between October 30, 2015, and January 28, 2016, and reviewed approximately 120,000 individuals within 1 of Medicare’s plans. The alerts identified Medicare members with 100 mg of morphine equivalent dose per day for a minimum of 60 consecutive days and using 3 or more prescribers and 3 or more pharmacies. The OMS targets those using more than 120 mg for a minimum of 90 consecutive days, and using 4 or more prescribers and 4 or more pharmacies.

The new program singled out 40 members who had least 1 claim meeting the criteria. Of those members, 7 were also identified by the CMS program, and 19 of them had appropriate override codes. There was 1 member who was discovered to be using buprenorphine/naloxone in addition to opioids, in spite of plans to discontinue opioid usage as per the clinical review notes. One member was subsequently enrolled in an opioid dependence treatment plan.

The researchers consider the DUR program successful because it identifies members as they attempt to fill prescriptions—much earlier than the CMS program. They believe that the edit will help reduce the amount of members identified for case management.