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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.
Another area of risk mitigation is in encouraging access to and use of naloxone to reverse overdoses. With more than 26,500 overdoses reversed just by laypeople between 1996 and 2014, naloxone is the only intervention that has demonstrated a direct link with opioid mortality, Lenz said. Advocacy efforts have increased access, and more and more states have statewide standing orders or pharmacist prescribing of naloxone. Some states include naloxone prescriptions within their PDMPs, but “we need to make sure that if it is incorporated, that we’re using it appropriately, and not penalizing patients for having that on their profile,” she warned.

Lenz provided several examples of state and local initiatives that have applied harm reduction theories to the use of naloxone to prevent overdose deaths. For instance, in the Prevention Point Pittsburgh program, all patients presenting to a pharmacy with an opioid prescription are counseled on overdose risk and offered naloxone. The Massachusetts Overdose Education and Naloxone Distribution program has partnered with needle exchange programs in 19 communities that have each seen reduced overdose deaths without increased opioid use. This program’s results were among the first to disprove the myth that harm reduction strategies drive opioid use, Lenz said.

According to Lenz, there are several harm reduction strategies that have shown promise internationally but have yet to be piloted in the United States, such as supervised injection sites and fentanyl testing strips. A pilot of the test strips in Vancouver found that 86% of heroin tested positive for fentanyl. While getting a positive result from these strips may not stop someone from using the drug, it can at least allow them to take the drug around someone who is able to rescue them with naloxone in case of an overdose.

Lenz sees the harm reduction strategies as holding more promise for preventing deaths than efforts to curb prescribing through PDMPs or drug rescheduling, which may actually push people to seek illicit substances if they can no longer obtain a prescription opioid.

Based on surveys conducted by the Addiction Advisory Group established by AMCP, recommendations for payers included removing barriers to timely naloxone access, encouraging continuity of care, and increasing awareness of and access to medication-assisted treatment. “Look at your policies, procedures, and benefit structure and ensure that you are actually reflecting substance use disorder as the chronic disease that we now know it is,” Lenz suggested.

Lenz also noted that about half of survey respondents said that bias and stigma affect payer coverage of SUD treatment, and most respondents’ plans are encouraging instead of requiring naloxone coprescribing with high-risk opioid prescriptions.

Because none of these tools will work universally, Lenz recommended that the audience should “go back and evaluate your strategies and ensure that you’re providing comprehensive strategies for patients, making sure that whatever strategy you use has the leeway to be flexible around their needs.”

These strategies should be tweaked as needed to ensure “that you’re providing the right balance of access to treatment for pain” against the risk of addiction, Lenz concluded.

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