Peter Salgo, MD: Let’s talk a little bit about medication overuse, shall we? I’m not going to use the word abuse. Let’s just say overuse. What is overuse and misuse? Are there clinical definitions, Stephen?
Stephen Silberstein, MD: Yeah, we arbitrarily defined it the following way. If somebody uses some medication for their headache 15 or more days a month, it’s overuse. If you use triptans, your butalbital 10 or more days a month, it’s defined as overuse. The reason that’s important is [that] it’s 1 of the major risk factors for having migraine headaches every day of your life, and it may prevent the [preventive] drugs from working.
Peter Salgo, MD: Do patients tend to overuse their drugs?
Stephen Silberstein, MD: The problem we have is that patients go to the pharmacy. And my favorite story is the Excedrin headache. [A] person is taking 4 Excedrin every day, and that headache is from the Excedrin. So overuse is common in patients who do not seek medical care.
Peter Salgo, MD: You chuckled. Why?
Shoshana Lipson: Yes, because it is a huge problem. It absolutely is. Sometimes with the prescription medications for those patients who do not have limits put on them for the number of triptans they can take. But also patients will tend to self-medicate, and so they’ll go to over-the-counter medications, and they end up taking this massive amount of combination prescription medications, over-the-counter medications, and anything else that they can throw in just to try to get their lives back.
Peter Salgo, MD: I can understand that. If I’m sitting there with a horrific headache, I’m going to take whatever it takes, in my view. The problem is, if I listen to everybody here, not a lot of folks are getting seen appropriately and getting told what [is] the best drug to take. Is that fair?
Shoshana Lipson: I would say that’s fair, although the idea of what is the best drug to take, it varies by person. I mean, we don’t yet know—correct me if I’m wrong, but the markers…[have] got to tell us which patient is going to respond to which medication. Or the implications—which patient is going to be able to tolerate which medication. But definitely, I would say the majority are not getting effective treatment at all.
Stephen Silberstein, MD: I would change your statement to the best drug for that patient.
Shoshana Lipson: Right, yes.
Peter Salgo, MD: Fair enough. But [what] we’re talking about, to go to what you said earlier, is millions of patients—tens of millions of patients and a small group of providers—who really know what they’re doing.
Shoshana Lipson: Right. And the added problem to that also is when you start on a medication that may not be the one that your physician has prescribed, for you but it’s the one that said the payer has said you need to get through this tiered system first, you often have to be on this medication at the right dose for up to 3 months to even see if it’s going to work. If that’s not effective and you’re having disabling migraine—not just talking about a little tension headache, but a disabling migraine with vision loss, and dizziness, and vertigo, and all the other symptoms that come—you can lose your job in that time.
Peter Salgo, MD: OK. Well, it’s all critically important. Speed seems to be important. Efficiency of diagnosis seems to be important. And there needs to be, it seems to me, a process for monitoring medication use and overuse. Is that process anywhere?
Maria Lopes, MD, MS: Well, 1 thing we do have is data around the claims that we do pay. So we certainly have data around the pharmacy part. If there’s a prescription that’s been written, the patients fill that prescription, whether it’s for triptans, whether it’s for barbiturates, whether it’s opioids. If we paid for it, we will have that in the claims system. So it’s a very good way of trying to understand what [do] the data mean and how can we intervene, particularly with referrals to the appropriate specialist. The other is ER [emergency department] visits and the cycling that occurs with these patients [who] are really seeking help.
Peter Salgo, MD: Help me with this a little bit. That’s an interesting piece to tease out. Are you telling me that you monitor claims for ER [emergency department] visits for patients [who] you know have headache and migraine, and that from that you can tell that something is getting a little screwy?
Maria Lopes, MD, MS: We monitor ER visits, and so if you are what we call a frequent flier into the emergency department, and if you have that data because if you’re a PBM [pharmacy benefit manager], bear in mind all you have is pharmacy data. You don’t have medical data, you don’t have ER encounters. So it’s certainly a good opportunity if you have both, but if you have 1 or the other, to be able to understand what is driving that utilization.
Wayne N. Burton, MD: I might add the pharmacy benefit design on the pharmacy side is having quantity frequency limits on medications for acute treatment. So if someone is exceeding that, there may be good reasons why they’re exceeding that. But if they’re not, then they should be on a preventive medication.
Peter Salgo, MD: I can see the problem, however, building here. If you have limits and someone comes in with a migraine and says, “I need my medicine.” [If] you said you reached your limit, [then] that migraine is not getting treated. What do you do?
Wayne N. Burton, MD: Well, a point there is, the reason for the limits is that some of those patients, many of them perhaps should be on a drug to prevent the migraine and not just be overusing, having medication overuse, whether it’s over-the-counter medication or prescription drugs. The second point is the opioid epidemic we have in the United States today and, unfortunately, migraineurs can be addicted to opioids. And if you have surveillance and oversight, this is another group [who]—instead of being on an opioid,—may need to be on 1 of the preventive medications to avoid that.
Peter Salgo, MD: Let me just throw this out there. Whenever I’ve heard a discussion of migraines, I almost never hear a discussion of opiates. I mean, among people who seem to know what they’re doing. Is there any place for opiates in migraine?
Stephen Silberstein, MD: Yes.
Peter Salgo, MD: Tell me why.
Stephen Silberstein, MD: There are 2 times they may be important. In the elderly [patients] prior to the new drugs that are being developed, if they have ulcerative disease, you can’t give them a nonsteroidal. If they have cardiovascular disease, you can’t give them a triptan. What else are you going to give them? That’s 1 time I would use it. The second time I might use it [is] if a woman [is] in pregnancy where she’s intractable, and you’re limited to what drugs that have been known to be safe. And the third time I might use it is [as] a last-resort rescue medicine if somebody is heading to the emergency department.
Shoshana Lipson: I’d like to add also, when you talked about the emergency [department], so a lot of people who have migraine do become what you would refer to as frequent fliers. But it’s not as easy as saying if someone becomes a frequent flier, then their migraine are out of control; and if they’re not, then they’re doing better. Because the emergency [department], quite frankly, is the worst place for someone with a migraine to be with the noise, the lights, the sound, the wait. So a lot of us would literally will not go there unless we think we’re dying.
Peter Salgo, MD: You can actually expand that. That’s pretty much the worst place for anything.
Shoshana Lipson: Right.
Stephen Silberstein, MD: And the treatment is frequently opioids.
Peter Salgo, MD: And it’s opioids, which may be the wrong treatment. How do you identify or can you identify medication misuse as opposed to overuse? Can you do it from a claims analysis?
Maria Lopes, MD, MS: That’s much more challenging because some of these medications can be used for other purposes. And so unless we’re prior authorizing the therapy for that specific indication and diagnosis, that’s a much more challenging analysis.
Peter Salgo, MD: Can you put a number on the healthcare cost with regard to medication overuse and medication misuse? Is there a way to do that?
Maria Lopes, MD, MS: Misuse, I think it would be very challenging unless you did an audit and know.
Peter Salgo, MD: What about overuse?
Maria Lopes, MD, MS: Overuse disorder. I’m going to say 10%, 15%.
Stephen Silberstein, MD: Half the patients with chronic migraine overuse the treatment.
Peter Salgo, MD: And how do you know this?
Stephen Silberstein, MD: Because of the surveys we have done.
Peter Salgo, MD: You’ve done surveys but it’s not on a closed-claims analysis. It’s just [that] you’ve done this clinically. If we think that overuse is a real problem, can you prevent it?
Shoshana Lipson: So theoretically, yes. But as Dr Silberstein said before, there [are] a lot of ifs. If you get to a doctor, if you get diagnosed, if you find a medication that works for you. So all the stars have to be aligned, and it’s very challenging to align those stars.