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The Balancing Act of Using Pharmacy Strategies to Fight the Opioid Epidemic

Christina Mattina
Utilization management tools and formulary designs are components of a multifaceted strategy to curb opioid overdose death rates, but they must be applied in a flexible manner, according to speakers at the Academy of Managed Care annual meeting.
Utilization management tools and formulary designs are components of a multifaceted strategy to curb opioid overdose death rates, but they must be applied in a flexible manner, according to speakers at the Academy of Managed Care Pharmacy (AMCP) annual meeting.

Bonnie C. Greenwood, PharmD, BCPS, clinical program director at University of Massachusetts Medical School, acknowledged that she could not give a perfect set of answers to solve the opioid crisis, but said she would share insights about what has worked for payers and managed care organizations as some of the tools in their toolbox.

She discussed a 4-pronged framework for managed care pharmacy strategies related to opioids: (1) establishing goals for safe prescribing and appropriate pain management; (2) expanding patient access to coordinated pain management and substance use disorder (SUD) treatment; (3) developing systems approaches to changing prescriber behavior; and (4) enhancing provider tools for screening, monitoring, and mitigating the risks of opioid therapy.

The safe prescribing goals are the foundation of the CDC’s guidelines for opioid prescribing, which have seen widespread uptake across the healthcare system but sparked concerns in the medical community over inappropriate applications, like the use of blanket dosage limits and other mandatory policies.

“This is not the first time the managed care pharmacy or payer community has heard the criticism of a one-size-fits-all approach when we’re trying to implement population-level change,” Greenwood said.

In terms of expanding patient access to pain management, she spoke of the importance of steering patients toward alternatives like nonopioid or nonpharmacological options. Step therapy, for instance, is an area of opportunity where payers can drive safer treatment courses by encouraging tactics like physical therapy instead of medication use for certain types of pain. However, the issue of “siloing” between pharmacy and medical benefits for these alternative treatments poses a challenge.

The systems approaches within the framework are where payers can employ traditional utilization management tools, often implementing many tools simultaneously. For instance, MassHealth, which is Massachusetts’ Medicaid program, requires prior authorization for high-dose opioid prescriptions and overlapping prescriptions. By imposing 3 sequential high-dose limits over a 15-year period, the average daily dose of opioids decreased after each step, the percentage of patients exceeding the limits decreased over time, and the greatest impact was seen in patients who used the highest doses. Importantly, this strategy allowed for multidisciplinary experts to discuss outliers and identify cases that should be exempt from the rules.

“We don’t have evidence that says this is exactly the right way,” Greenwood said. “…What’s very important here is that any time you are implementing a tool such as this, that it’s informed by the evidence.” This evidence can come from national literature or from looking at a plan’s own data, she added.

Joining Greenwood to discuss the fourth component of the framework was Kimberly Lenz, PharmD, clinical pharmacy manager, of MassHealth/Office of Clinical Affairs and University of Massachusetts Medical School. When looking to monitor and mitigate the risks of opioids, patient review and restriction programs can help drive safer utilization by “locking in” patients to one specific provider or pharmacy, Lenz said. Additionally, giving managed care organizations access to the state prescription drug monitoring program (PDMP) can be beneficial to both member and payer if it results in better coordination of care.

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