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The Role of Managed Care Professionals and Pharmacists in Combating Opioid Abuse
Kirk Moberg, MD, PhD

The Role of Managed Care Professionals and Pharmacists in Combating Opioid Abuse

Kirk Moberg, MD, PhD
These delays created uncompensated work for clinicians that translated into increased overhead costs for clinical practices. Estimated costs of prior authorization included27:
  • 1 physician hour per week27
  • 13.1 nursing hours per week27
  • 6.3 clerical hours per week27,30
  • $2161 to $3430 annually per full-time-equivalent (FTE) physician27,31
  • $89,975 in interactions with insurers annually per physician27,32
Because of this burden on physicians and their fellow clinicians and staff, the AMA and 16 other partner medical society and specialty organizations have proposed programs and processes centered on clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, and alternatives and exemptions for improvement of the PA process. Based on outlined principles, these recommendations focus on these noted areas to streamline requirements, lengthy assessments, and inconsistent rules that negatively impact current PA programs.28,33

Managed Care and Pharmacy Opportunities for Preventing Opioid Abuse/Misuse

Managed care providers and professionals must strive to achieve concomitant goals of ensuring that patients with legitimate pain have access to opioid pain medications when truly necessary while minimizing opioid misuse. Internal strategies to accomplish this may include pharmacy and prescriber controls that limit reimbursement to ensure that higher risk opioids are not provided unless their benefits exceed their inherent risks and that appropriate drug use monitoring is employed. Using opioid formulations that minimize abuse/diversion is another valuable tool, as is surveillance of claims data for overuse of opioid agents. Claims data can also identify individuals at greater risk for drug abuse, including those with mental health disorders and substance use issues.34 Clinicians may adopt “universal precautions” in working with these patients, including screening and risk stratification for opioid abuse/misuse, patient education and counseling that encourages patient involvement in decision making and therapy, use of UDTs, pill counts, or other measures to assess for problems, and careful documentation of the entire pain management process.34,35 The use of Screening, Brief Intervention, and Referral to Treatment may also be implemented, using brief interventions or treatment for low to moderate risk cases and referral to a pain specialist for high-risk patients. In addition, case management offering support to clinicians, and especially patient education and increased communication between clinicians/providers and patients, can all enhance the pain-management process and reduce risks and events associated with opioid abuse/misuse.34,36

Pharmacists are also valuable stakeholders in ensuring safe use of opioid drugs.37 Pharmacists can incorporate risk-stratified opioid screening in everyday practice by asking open-ended questions and actively listening for potential clues that suggest opioid misuse. Data within the Controlled Substance Reporting System also permits pharmacists to identify patients at increased risk for opioid overdose, including those taking high-dose agents, filling multiple prescriptions for different drugs, or patients obtaining opioids from multiple prescribers or several different pharmacies.37,38 Pharmacists must also be vigilant about instructing patients on safe opioid storage and disposal. A study by Kennedy-Hendricks et al reported that 48.7% of adults receiving prescriptions for opioids did not recall receiving instructions on safe storage of these agents, and 45.3% did not receive explanations on safe disposal.37,39 Overall, pharmacists must serve as a critical line of defense against opioid misuse and abuse by more active engagement in preventing and helping to treat opioid use disorders.37

Outside resources also benefit patients with chronic pain taking opioid medications. Patients with chronic pain frequently require a management approach that allows them to talk freely about their pain and gain support for how they are feeling while also being aided to adapt to an active and meaningful life alongside their pain. Psychotherapy or other consultation with a behavioral health specialist can enhance this process.40 It is also important to recognize when a patient may be developing a substance use disorder and may need referral to an addiction specialist for treatment and management, including41:
  • When a brief assessment or intervention is not adequate for optimal management
  • When opioid or illicit drug abuse is suspected
  • When a patient has a complex medical history or a previous history of substance abuse and requires more intensive treatment than can be provided in the current clinical setting
  • When a patient is noncompliant with treatment protocols or clinical practice policies surrounding opioid therapy
  • When a patient is showing dependence on high-dose long-acting or short-acting opioids, or is requesting a transfer from high-dose methadone maintenance
  • When a patient requests a referral for treatment of substance abuse

Optimal treatment of chronic pain remains a dilemma in the United States, and the detrimental impact of opioid misuse has inflicted serious clinical and economic complications on patient management and public health overall. Healthcare professionals must be better prepared to appropriately evaluate opioid treatment options and better delineate their safe administration, efficacy, and safety, including guidelines for management, the best use of ADFs, and how PA and specialty referral may benefit overall patient management. It is most important to concentrate on individualized management based on clinician and patient collaboration surrounding therapy to select the best treatment options that offer clinical benefit and patient safety and reduce the potential for opioid misuse and addiction and their associated clinical and economic burden. 

Author affiliation: Illinois Institute for Recovery, UnityPoint Health, Departments of Internal Medicine & Psychiatry, University of Illinois College of Medicine, Peoria, Illinois.
Funding source: This activity is supported by an educational grant from Daiichi Sankyo, Inc.
Author disclosure: Dr Moberg has no relevant financial relationships with commercial interests to disclose.
Authorship information: Analysis and interpretation of data; concept and design; critical revision of the manuscript for important intellectual content; drafting of the manuscript; supervision.
Address correspondence to:
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