Here are certain facts that every executive responsible for managing populations at risk for prescription drug misuse should know as they make policy decisions affecting patient care and financial management.
A 21-year-old woman from Palm Beach, Florida, whose cause of death was attributed to a combination of fentanyl and cocaine. A 30-year-old “loving son and friend” from Hillsborough, North Carolina, who overdosed on opioid and heroin following a decade of struggle with addiction. A 67-year-old woman in Texas who originally got hooked on hydromorphone, an opioid analgesic, and now spends her Social Security checks on methamphetamine.
These real stories of death and devastation from substance misuse, all from 2018, are not the exception-they are the norm. New data from the CDC show that 70,237 people died in 2017 from drug overdoses-a staggering figure that tops the highest numbers of deaths from other public health crises like HIV/AIDS, car crashes, and gun violence.
In many ways, managed care organizations are on the front lines of this crisis. They largely set the parameters by which physicians prescribe opioids, amphetamines, benzodiazepines, and other drugs that are prone to misuse.
They also shoulder much of the costs. Recent estimates place economic costs for the opioid crisis as high as $504 billion alone. That does not include other forms of prescription drug misuse, such as wasted dollars on medications filled but never used.
As the opioid crisis continues to unfold, there are certain facts that every executive responsible for managing populations at risk for prescription drug misuse should know as they make policy decisions affecting patient care and financial management.
Fact 1: Everyone is at risk of prescription drug misuse
To start, physicians and other prescribers should not make assumptions about who is at risk. A recent analysis that I co-authored, based on 3.9 million de-identified test results performed for patients by Quest Diagnostics, showed that half of Americans misuse their prescription medications, and that prescription drug misuse was not confined to any single patient category-high rates of misuse spanned age groups, health plans, and gender. There is no discernable profile of someone at risk of misuse. Everyone is at risk.
In addition to health risks, this high rate of misuse is associated with cost increases: a 2017 study in the Journal of Managed Care & Specialty Pharmacy showed individuals diagnosed with abuse incur annual excess healthcare costs of over $14,000 compared to those without.
Fact 2: Prescription drug misuse is bigger than opioids
The Quest analysis showed misuse rate in 2017 was 52%, roughly the same rate it has been for the last few years, suggesting that educational initiatives to curb misuse have plateaued. But opioid medications are not the only drug being misused: tests results showed high misuse rates of multiple substances, including amphetamines, benzodiazepines, cocaine, and alcohol.
Rates of medication nonadherence were especially troubling. Of the 52% of results that showed evidence of misuse, 34% did not show the drugs they had been prescribed, and 22% did not show the drugs they had been prescribed but were positive for other illicit or non-prescribed drugs.
Medication nonadherence contributes to healthcare waste, ineffective treatment and the potential for unintentional or criminal diversion. It is also associated with higher rates of hospital admissions and suboptimal health outcomes as well as increased healthcare costs of approximately $100 to $300 billion of U.S. healthcare dollars spent annually.
Fact 3: Opioid/benzodiazepine drug combining is prevalent
Our Quest data also showed that more than one in five test results revealed potentially dangerous concurrent use of opioids and benzodiazepines-and in nearly two-thirds of these cases (64%) indicated that at least one of the drugs was not prescribed.
Both opioids and benzodiazepines depress the central nervous system. When combined, they can cause respiratory suppression, cardiac distress and even death. A 2014
by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates a steady increase in emergency department visits between 2005 and 2011 for events related to a combined intake of opioids and benzodiazepines.
Older Americans, who experience higher rates of chronic pain, are at particular risk. The Quest analysis found that Americans covered by Medicare had higher general misuse rates involving opioid/benzodiazepine combining than those covered by Medicaid or private insurance and the highest rate of concurrent use of opioids/benzodiazepines (30.8%) of all age groupings.
Fact 4: Opioids will continue to be essential to pain relief
With all the concerns about the opioid addition, it’s easy to forget that the beginning of the prescription opioid epidemic began with attempts to address another healthcare crisis: chronic pain. About one in five American adults suffers from chronic pain, according to recent estimates from the CDC.
While sharp reductions by policy makers on opioid prescribing are critical to preventing misuse, FDA Commissioner Scott Gottlieb recently noted that, “…even as we seek to curb overprescribing of opioids, we also must make sure that patients with a true medical need for these drugs can access these therapies.”
Tragically, some patients turn to illicit drugs to relieve their pain when access to opioid therapy is curtailed. The surging rates of deaths due to heroin and synthetic fentanyl-numbering nearly 30,000 in 2017, an increase of more than 9,000 over 2016-underscore that use of non-controlled opioids is both prevalent and dangerous.
What are the takeaways for managed care executives?
First, policies that sharply restrict opioid prescribing are not a cure-all for the opioid crisis. Guidelines from the CDC, and organizations such as the American Society of Interventional Pain Physicians, suggest that opioids are not first-line or monotherapy, and a prudent “start low, go slow” approach should be taken to opioid prescribing for pain.
Second, pharmacy benefit managers (PBMs) play an increasingly important role in ensuring that patients use medication correctly. Unfortunately, the new Support for Patients and Communities Act still doesn’t give health plans access to state prescription drug monitoring program (PDMP) data. But PBMs leverage the plan’s prescribing data with clinical care management intelligence to examine a patient’s prescription drug profile and identify patients with overutilization or polypharmacy. The PBM communicates concerns about repetitive claims and deviations in pharmacy patterns to the plan pharmacist, who investigates in collaboration with the prescribing physician.
As the drug epidemic expands beyond prescription opioids, health plans can supplement the efforts of PBMs with patient drug monitoring to decrease the risk of misuse while ensuring patients are using their medications as prescribed. The CDC, American Society of Addiction Medicine (ASAM) and other reputable groups recognize the value of laboratory monitoring because it provides objective insight into actual drug use. The ASAM guidelines provide specific guidance for appropriate use of presumptive and definitive drug testing for individuals at risk for misuse and SUD.
There are too many tragic stories associated with drug misuse, and limited resources available to fight the drug epidemic. Managed care organizations can make the best use of those resources while impacting the potential personal and economic devastation of the U.S. drug epidemic.
Jeffrey Gudin, MD, is medical advisor for Quest Diagnostics and director of pain and palliative care at Englewood Hospital and Medical Center, New Jersey.