Caroline Carney, MD, MSc, FAPM, CPHQ

Caroline Carney, MD, MSc, is the chief medical officer for Magellan Rx Management, the pharmacy benefit management division of 

. She joined Magellan Health in 2016 and previously served as the chief medical officer for Magellan Healthcare. In her current role, Carney is broadly responsible for supporting Magellan Rx in building differentiated, industry-leading clinical programs and services. Prior to joining Magellan, Carney served in chief medical officer roles, working with Medicare, Medicaid, commercial, and exchange populations. She was trained in and practiced psychiatry, internal medicine, and psychosomatic medicine. Carney has a Master’s degree in preventive medicine, focusing on health services research and epidemiology. She also brings strong public sector expertise having served as medical director for Indiana’s Office of Medicaid Policy and Planning where she oversaw quality, pay for performance, and initiatives for behavioral and physical health.

In recent years, fatal overdoses from fentanyl have drastically increased across the nation, with the number of deaths nearly doubling each year from 2013 through 2016. The data point to the emergence of the third wave of the nation’s opioid epidemic—fentanyl.

 released by the CDC highlights alarming trends characterizing this third wave and its impact across a wide variety of demographic groups:

Three times as many men as women are dying from fentanyl, although death rates have increased exponentially among both genders.

Death rates among teens and young adults (ages 15-34) are especially steep. Among 25- to 34-year-olds, the percentage of deaths involving fentanyl doubled each year from 2011 to 2016.

Recent increases in fentanyl deaths among 35- to 44-year-olds are also of grave concern: Death rates for this age group rose more than 123% per year from 2013 to 2016.

From 2011 to 2016, the number of fentanyl deaths was higher for whites than for other ethnic groups. However, overdose deaths rose faster year over year for blacks (140.6% per year) and Hispanics (118.3%) during this period.

Why are fentanyl death rates increasing so rapidly? Fentanyl is 50 to 100 times more potent than morphine, meaning it takes very little of the drug to cause a fatal overdose. Not only is it extremely addictive and dangerous, with the potential to 

, but it can also be manufactured cheaply and easily in a synthetic formula in a lab, substantially increasing its availability. Because it comes in many forms—tablets, powders, liquid, and patches&mdash;synthetic fentanyl is often mislabeled or mixed with other drugs on the black market. As a result, many people who have overdosed on fentanyl are unaware the drug that was taken was laced with fentanyl.

Further, our country’s laws and medical guidelines have made access to prescription opioids much more difficult—and that’s a good thing. Unfortunately, decreased access has prompted many people suffering from substance use disorder to turn to heroin. This, in turn, has increased exposure to fentanyl.  

While the rapid rise in deaths due to fentanyl is another tragic outcome in the growing opioid epidemic, it’s a crisis that can be combatted with education, awareness, and the right precautions. The following are 4 key strategies that can make a material difference.

1. Recognize opioid addiction and encourage evidence-based treatment

A critical step in combatting the rise of fentanyl and opioid overdose starts with education. Educate members and their families, friends, and loved ones on the signs of opioid addiction—and support access to evidence-based treatment. 

Regularly taking an opioid in a way that was not intended

Borrowing medication from other people or "losing" medications to gain additional prescriptions

When addiction is detected, one of the most effective ways to combat opioid addiction is through medication-assisted treatment (MAT), an evidence-based approach to help those with opioid use disorder (OUD) return to health. When combined with psychosocial interventions like psychotherapy and contingency management, MAT empowers those with OUD to recover from their addiction while allowing them to rebuild their lives.

Naloxone can save lives by reversing the effects of an opioid overdose. It’s important to proactively speak with health providers and insurance companies to ensure access to naloxone for those battling opioid addiction.

The US Surgeon General recommends the following groups of people 

Those currently taking high doses of prescription opioids for pain

People who are misusing prescription opioids

Individuals taking illicit opioids, such as heroin or fentanyl

Family members whose loved ones suffer from OUD

People who regularly come into contact with those at risk of an opioid overdose

Health plans can support access to naloxone through policies that make this medication readily available to those suffering from OUD and their support teams. They should also seek to educate providers on the benefits of access to naloxone for high-risk individuals.

3. Foster safe opioid usage, when necessary

When opioids must be used in treatment, work with providers to establish safe guidelines for use. For example, take steps to ensure the morphine milligram equivalent dose, duration of treatment, and type of opioid prescribed (eg, long- or short-acting opioids) follow the CDC and CMS best practices.

Additionally, pairing those taking opioids with chronic pain management coaches and offering these individuals 24/7 access to healthcare professionals, such as a hotline staffed by nurses or an outside service, will provide a critical resource for members who need help understanding their opioid prescription or feel as if they have a problem managing their response to their medication.  

Stay up to date on community, medical, and legal resources directed at combatting addiction and limiting the availability of opioids. For example, the 

 passed last year provides practical policy solutions for addressing the opioid crisis, including the use of telehealth services for OUD treatment. In communities with limited resources for one-on-one OUD support, telehealth services or a combination of virtual and in-office services provide the basis for an evidence-based approach to care.

It’s also important that health plans, providers, and community groups work together to identify specific populations at risk and develop targeted outreach and recovery support. Such initiatives can help members feel more empowered to successfully recover and transition back into society.

With new factors continuing to emerge every day in the growing opioid epidemic, now is the time to take proactive measures to better protect communities across the nation. Through education, support for evidence-based treatment and naloxone access, and partnership with families, providers, and community service agencies, we can help ensure those with OUD receive the right support at the right time, putting them back on a path of sobriety and health.

Articles

In recent years, fatal overdoses from fentanyl have drastically increased across the nation, with the number of deaths nearly doubling each year from 2013 through 2016.

4 Strategies for Combatting the Third Wave of the Opioid Epidemic: Fentanyl

As consumer preference continues to help shape the way in which care is delivered, the need for patient-focused innovation is critical. One key area where this approach can result in improved quality of care and reduced costs is drug management.

While the industry has made significant progress in recent years, there is still much we can do to drive a better patient experience around pharmaceuticals, starting from the point a drug is prescribed to when it is received and ultimately taken or administered. With the opportunity to leverage data in real time, we can more effectively prescribe medications, predict the likelihood of medication adherence, and design appropriate strategies to support adherence. We can even predict which medications a patient may require in the future based on factors such as drug history, health history, drug metabolism, and age. Further, we can design ways to more effectively work with physicians at the point of prescribing to ensure the decisions made are right for the patient and for the circumstance.

At Magellan Rx Management, we’ve taken a high-tech, high-touch approach to drug management that has significantly impacted behavior change in both patients and providers, supporting improved outcomes and a better overall experience. It’s a model that leverages data-driven solutions to deliver highly personalized services and higher-quality care at lower cost. We do not take a one-size-fits-all approach and are keenly aware that prescribing and interventions need to be individualized. 

The following are ways this unique model is redefining pharmacy benefit management and enhancing the experience for patients and providers alike.

High-Touch Decision Support Tools Aid Physicians in Ordering Complicated Drug Regimens

Today, roughly half of total pharmacy spend is driven by specialty drugs, with half of that specialty spend covered under the medical benefit. This portion of specialty spend is typically unmanaged by pharmacy benefit managers and health plans. Decision support tools we’ve built for specialty physicians ensure drugs are being administered at the most clinically appropriate site of service and are appropriately utilized.

Oncology drug regimens, for example, are very complicated. There are a number of individual factors that can determine success, such as the type of cancer the patient has, the patient’s genetic markers and medical history, and social determinants of health, along with many different drug combinations that have been used over time. The shifting regulatory landscape around guidelines for these regimens adds an additional layer of complexity. In instances where more information is needed to make a coverage decision, scheduling a high-touch peer-to-peer discussion with the prescribing physician to explain why the regimen requested may not be the appropriate regimen and working with the oncologist to determine the right approach for the patient is key. During these discussions, physicians are paired with an expert from their specialty. This model eliminates the frustration that accompanies a simple denial of coverage and provides the education and support needed to both improve outcomes and lower costs.

Accounting for up to 50% of treatment failures and more than 100,000 deaths per year, medication nonadherence can have a significant impact on patient outcomes. To improve the outlook, we’re exploring unique ways to improve medication adherence through patient rewards. For example, in collaboration with AiCure, we are piloting an artificial intelligence platform that captures and understands video, audio, and behavioral data to maximize clinical outcomes. The Virtual Rx Assistant engages patients and visually confirms they take their prescription. For instance, patients with hepatitis C take expensive medication for 8 to 12 weeks, costing approximately $24,000 total. If the medication is not taken correctly, there are significant health impacts and risk of not reaching the desired clinical response. Patients download the application onto their smartphone. The application uses computer vision and neural networks to visually ensure the correct patient is taking the correct medication. The automated system takes 5 to 10 seconds to use.

In addition to dosing data, other behavioral and physiological characteristics can also be analyzed to further analyze treatment response. The early results are outstanding: 96% of patients in the pilot have adhered to their treatment regimen. It’s one way in which innovation is driving improved outcomes and patient satisfaction while reducing healthcare costs.

Additionally, digital therapeutic apps are beginning to be approved by the FDA for treating conditions such as substance abuse, insomnia, depression, anxiety and more. With strong data demonstrating the success of such programs, digital therapeutics offer the potential to improve the impact of medications, avoid medication side effects, and curb the inappropriate use of pharmaceuticals for certain health conditions.

We also recognize that the way in which patients consume information is rapidly changing, requiring new approaches to communicating with them about their care plans and medications. Last year, Magellan partnered with VUCA Health to create educational videos presented by pharmacists, with a focus on helping patients understand:

The benefits of medication therapy management

Key aspects of prescription drug coverage

This initiative helps ensure patients are informed about complex concepts like prior authorizations and medication safety in a nontraditional format that’s convenient for them. It’s an approach designed to boost medication adherence by increasing health literacy.

While rapidly changing, it is an exciting time to be in healthcare. We’re seeing enormous advancements being made in the areas of precision medicine, pharmaceuticals and digital therapeutics that are changing lives by improving not only outcomes, but also access to care. But there is still a long way to go toward applying technology and innovation to the consumer pharmaceutical experience. Committing toward high-tech, high-touch pharmaceutical innovation is one way to bend the value curve in healthcare while improving health and the patient experience.

Building a High-Tech, High-Touch Model for Drug Management

One out of 4 patients who receive long-term opioid therapy in primary care settings struggle with opioid use disorder, according to CDC 

. While conversations around opioid addiction are beginning to impact physician prescribing patterns, there is still much progress to be made around treatment and recovery solutions for those battling opioid use disorder.

One important option that requires greater attention: the need to leverage an integrated team approach in opioid treatment and recovery.

 points to the value of a holistic approach to opioid recovery delivered in a community setting. Such an approach may include relapse prevention medications; group and individual counseling; physician visits for medication management; mental health therapy; and psychiatric treatment for co-occurring disorders. But there are barriers to accessing holistic opioid recovery treatment within the patient’s community, such as a 

, stigmas associated with certain treatment options, limited availability of specialized providers, difficulties navigating the complexities of substance abuse treatment, and insufficient capacity.

Overcoming the challenges to a holistic approach to opioid recovery is critical to engaging patients safely and comfortably, and to supporting sustained recovery. The following 5 elements contribute to a successful integrated approach.

1. Confront the stigmas associated with opioid addiction treatment

Medication-assisted treatment (MAT), an evidence-based approach that combines medication with psychosocial intervention, is considered the gold standard in treatment for opioid addiction. MAT works by decreasing opioid cravings and mitigating the effects of withdrawal. It has been proven to be highly effective in treating opioid addiction: In 1 study, more than half of patients treated with MAT 

However, there is a stigma often associated with MAT—both on the part of medical professionals, including addiction recovery professionals, and family members. Some believe use of MAT simply replaces 1 addiction with another. Additionally, physicians who treat patients addicted to opioids often cite a lack of care management staff, space, and psychosocial support services as 

. Lack of understanding around how, and how long to administer MAT also contributes to low adoption rates.

Confronting the stigmas associated with the use of MAT is critical to supporting successful recovery. By providing MAT education for physicians, addiction professionals, and family members, healthcare leaders not only will support improved outcomes for patients, but also help to erase the stigma associated with prescribing such treatment. Consider lunch-and-learn sessions for physicians, nurses and other healthcare professionals, presentations for family support groups, and online education for family members.  

2. Combine MAT with supportive psychosocial interventions

When combined with psychosocial interventions, MAT not only saves lives, but helps patients 

gain the skills and social networks needed

 to support long-term recovery. Psychosocial interventions address the whole healthcare needs of those suffering from opioid addiction by identifying and addressing conditions that may have led to abuse. Research shows that patients using opioids who are treated with MAT combined with psychosocial interventions 

 than those who are not. Explore partnerships with behavioral health specialists for a holistic approach to care that results in patient-specific treatment plans.

3. Address the physical problems that could contribute to addiction

Pain relief is the most common reason patients misuse opioids, according to the 

2015 National Survey on Drug Use and Health

. That’s one reason why an integrated, team-based approach to opioid treatment and recovery is so important: treatment of pain is patient-specific, and specially trained professionals are needed to ensure an effective approach.

Pain management professionals can help those suffering from opioid addiction find alternative medications or techniques for managing the pain of their underlying physical condition. For example, pain management coaches can work 1-on-1 with opioid addicts to explore healthy, effective approaches for pain relief, such as through digital therapy and motivational interviewing. Getting the right kind of exercise is a mainstay for persons with chronic pain—and working with a physical therapist or pain specialist is important in matching the right type of exercise to the specific reason that pain may be occurring. Cognitive-based therapy, a form of psychotherapy, is also as effective as pain medications in many cases. 

4. Consider a virtual or mixed-model approach to treatment

In communities with limited resources for 1-on-1 opioid recovery support, telehealth services or a combination of virtual and in-office services provide the basis for an integrated care approach. For example, telehealth case managers can serve as the addict’s first point of contact throughout the recovery process. They can also assist physicians and staff in detecting the warning signs of opioid addiction and relapse. Additionally, telehealth counselors can help meet the mental and behavioral health needs of difficult-to-treat patients.

Certified recovery specialists also are an effective support resource for those recovering from opioid addiction—and this support can be provided in person or virtually. Through coaching, encouragement and connection with community resources, certified recovery support specialists create supportive environments for people in treatment that aid in their recovery journey.

5. Involve family members in the opioid recovery process

Difficulties managing family conflict are a 

 to opioid abuse. When families are involved in the recovery process, healthcare professionals find opportunities not only to holistically address the family dynamics that may have contributed to abuse, but also learn more about the patient from those who know the patient best. Such insights could prove essential not only in designing an individualized treatment plan, but also in uncovering details regarding the patient’s history, habits and relationships that may impact treatment.

In the fight against the opioid epidemic, a holistic view of the whole health needs of those suffering from addiction is critical. Without widespread access to an integrated treatment approach, patients face a challenging battle in their transition from addiction to health. Innovative and integrated approaches to opioid recovery and treatment are key to empowering patients to overcome their addiction and lead healthy, vibrant lives.

Overcoming the challenges to a holistic approach to opioid recovery is critical to engaging patients safely and comfortably, and to supporting sustained recovery. Here are 5 elements that contribute to a successful integrated approach.

The Importance of Integrated Care in Fighting Opioid Use Disorder

 die from prescription opioid overdoses every day, while the number of deaths from prescription opioids has 

 since 1999. Lack of expertise on how to measure and treat pain is a large factor driving the crisis. In addition, challenges in identifying those who are at risk for opioid abuse or who are already dependent on opioids adds further complexity.

Americans consume 80% of opioid painkillers produced worldwide. Yet the amount of pain reported 

 since in the past 2 decades, according to the CDC. For physicians, this points to the need to reconsider when to prescribe an opioid—if at all. Providers face intense pressures to adequately treat pain and may not know the data that supports nonopioid therapies. 

Breaking the cycle of prescription opioid abuse requires new thinking around pain management and alternative options for helping patients deal with chronic pain. The following are 6 things physicians should consider before prescribing an opioid.

1. Evaluate whether cognitive behavioral therapy could be the patient’s first defense against chronic pain

Cognitive behavioral therapy is a type of psychotherapy that helps patients better cope with challenges by identifying triggers to pain, behaviors and emotional responses, including chronic physical symptoms, life stresses, anxiety, and psychological trauma. Some cognitive behavioral therapy techniques seek to change patients’ behavioral patterns through relaxation techniques, role playing and learning to face one’s fears rather than avoiding them. Others focus on changing patients’ emotional mindset by encouraging patients to think about their problems in a different light.  

Today, digital and virtual solutions for cognitive behavioral therapy give patients access to counseling modules for a number of conditions, providing on-demand and flexible access to therapy via a computer or an app. Often, patients can access to cognitive behavioral therapy for free through the employee assistance programs offered through employers or insurers.

2. Determine whether the patient has an underlying condition that could contribute to the perception of pain

Recent studies indicate that for some conditions, depression and anxiety can 

 a patient’s perception of pain; so can 

. That’s why effective treatment of chronic pain involves more than managing the patient’s physical symptoms—it also requires careful evaluation of the ways in which the patient’s mood, mental health, and outside stressors might be amplifying the patient’s response to those symptoms. Screening tools can help physicians determine whether patients have mental health conditions that have previously gone undiagnosed. In some instances, screening results might also point to an existing substance use disorder that has gone undetected.

3. Explore whether complementary therapies might provide long-term relief

Low-impact physical activities, such as yoga, walking, or swimming, have the potential to ease chronic pain without the use of pain medication. Yet complementary treatments, including physical therapy, are often underutilized in treating chronic pain. 

 shows that physical activity not only reduces secondary muscle tension and improves stress tolerance, but also influences the perception of pain. Consider exploring options for activities and therapy that could help patients avoid pharmacological treatment and provide long-term relief.

Weight loss also may provide the relief patients seek and is a healthier alternative to pain medications. Even a five-pound weight loss can reduce pain levels for patients suffering from chronic conditions by improving the spatial distribution of pain, according to a 2017 University of Michigan 

. Look for a medically led program that helps patients lose weight safely while monitoring their overall health.

Some physicians, such as surgeons, feel pressure to prescribe opioids to treat pain, especially when quality programs rate providers in part by how well they manage pain—and scores may be linked closely to reimbursement. Pain management coaches can help physicians determine when opioids are truly needed and when alternative medications or approaches should be explored to help the patient find relief.

Pain management coaches use digital therapy and motivational interviewing to help patients manage their pain without turning to opioids. When patients are prescribed a short-term dose of opioids, pain management coaches also can be used to help transition patients off opioids by teaching patients techniques to manage their pain without turning to opioids.

5. If pain pills are determined to be the right treatment, consider whether a nonopioid medication is the best choice

For example, would prescription-level doses of ibuprofen or acetaminophen, combined with physical therapy, cognitive behavioral therapy or weight loss, have the potential to help the patient? Would interventional treatments, such as injections guided by interventional radiology to reach the precise site where pain emanates, be an option for relief? Is the core cause for pain being properly treated? If the patient has a condition such as rheumatoid arthritis or Crohn’s disease, could infusion of pain medication, delivered under a nurse’s supervision, be a viable alternative? There are many options for treatment that could—and should&mdash;be explored before prescribing an opioid.

Partner with pharmacists or other experts in medication management in determining which alternative medication options could be right for the patient before prescribing an opioid. Given the high risk of opioid addiction after just four to five days of use, it’s critical that physicians are absolutely certain that an opioid is the right choice for the patient before a prescription is written.  

6. Counsel the patient before prescribing

Much like using informed consent, patients need to know the risks and benefits of using opioids, including significant side effects like constipation and mental status changes. Teach patients about the expected trajectory of pain and how long-term use of opioids may be more harmful. Providers can use their state’s controlled substance prescription monitoring data to understand whether the patient is at high risk for addiction by understanding whether the patient receives narcotics or other risky medications from other providers. In cases where pain is expected to be short-term, limit the number of tablets prescribed, and provide step-down instructions for other forms of pain. 

Opioids are meant to provide short-term relief from pain; they are not intended to be a long-term solution. By exploring alternatives to the use of opioids in managing patients’ pain, physicians not only will help prevent the continued spread of opioid addiction, but also will give patients the tools they need to live happier, healthier lives.

Breaking the cycle of prescription opioid abuse requires new thinking around pain management and alternative options for helping patients deal with chronic pain. Here are 6 things physicians should consider before prescribing an opioid.

Caroline Carney, MD, MSc, FAPM, CPHQ

Articles

4 Strategies for Combatting the Third Wave of the Opioid Epidemic: Fentanyl

Building a High-Tech, High-Touch Model for Drug Management

The Importance of Integrated Care in Fighting Opioid Use Disorder

Six Things to Consider Before Prescribing an Opioid