Plan, PBM programs help identify prescription drug abusers

The elderly are among those most vulnerable to prescription drug abuse or misuse because they are prescribed more medications than their younger counterparts. However, a report by the University of Michigan shows that 15% of high-school seniors said they used a prescription for non-medical reasons in the prior year, and that overall use of prescription drugs by teenagers has risen over the past decade.

One of the most effective ways to curb the problem of abuse of prescription drugs is to track prescribing patterns, match claims against criteria for use of drugs that invite abuse and let physicians know there may be a problem. Although a PBM cannot tell what a drug is prescribed for, it can see all the claims-if paid for by insurance-regardless of the source of the prescription, says Randy Vogenberg, chief strategy officer for EPS LLP, a pharmacy consulting company in Cranston, R.I. A PBM can provide real-time data, he notes.

REVIEWING DRUG UTILIZATION

Prescription Solutions, a PBM in Irvine, Calif., developed the Narcotic Drug Utilization Review Program to promote the prevention of adverse drug events that may occur with narcotic drugs used for the treatment of acute or chronic pain, such as Vicodin (hydrocodone bitartrate and acetaminophen), OxyContin (oxycodone), and morphine.

The PBM identifies members taking multiple narcotics that exceed the usual limits and notifies their physicians, who receive patient-specific reports of use and clinical guidelines for using these drugs. In turn, physicians can take appropriate measures to prevent duplicate therapy by talking with members and finding ways to optimize pain management therapy. "If a plan member uses insurance to pay for a drug, the claim will pass through to us so that we can track it," says Brian Solow, MD, vice president and medical director for clinical services for Prescription Solutions. "I find it surprising how many patients use their insurance instead of paying out-of-pocket for these drugs. It is easy to dupe the system by doctor or pharmacy shopping when claims can't be tracked."

In an initial intervention of potentially inappropriate opioid use, Prescription Solutions identified 3,180 patients and another 4,045 in a second intervention. The utilization program helped resolve at least one problem-most of them related to use of multiple physicians or pharmacies-for as many as 80% of identified patients.

Thom Stambaugh, chief pharmacy officer at CIGNA Pharmacy Management, Bloomfield, Conn., concurs with Dr. Solow. "The issue of abusing prescription drugs is a delicate balance of ensuring access to appropriate pain medications for those who need it and avoiding abuse," he says.

CIGNA relies on predictive modeling to identify patterns of abuse, fraud and addiction and once identified, leverages its integrated approach to healthcare.

"We look at the medical diagnosis, where the patient was treated, if they have behavioral or substance abuse problems and if they are seeing multiple physicians or visiting more than one pharmacy. Once we find someone who may fit one or all of these criteria, we notify their physicians, who are both appreciative and often surprised," Stambaugh says.

With e-prescribing, it is possible to prevent a duplicate prescription before it is even dispensed. Physicians are able to enroll patients in substance abuse programs, or make the appropriate authorities aware if it is an issue of fraud.