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How do we keep opioid pain relief from destroying lives?

Jun 21 2016
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Prescription opioid painkillers can bring relief from crippling pain. Too often, though, they ruin and even end the lives they were meant to help.

Almost 19,000 Americans died of prescription opioid overdoses in 2014 — more than four times the 1999 toll.

How can we keep a medical treatment from destroying lives through misuse, over-use, accidental overdose, diversion into recreational use, or addiction?

Insurers like Aetna are in a position to try to help. Because they see claims for the prescriptions a patient fills including prescriptions from various doctors or dentists filled at various pharmacies, insurers have the chance to catch potential dangers that others may miss. They can raise a red flag, reach out to the patient and those prescribing the drugs, offer education and treatment, and potentially ward off disaster before it’s too late.

“Our goals are to reduce supply, manage appropriate use, increase adoption of medication-assisted treatment, and reduce the rate of opioid related overdoses, ER visits, and deaths,” said Hyong Un, M.D., chief psychiatric officer of Aetna Behavioral Health.

Step 1: Preventing opioid misuse, overuse

One of the best ways to prevent misuse or addiction is to find alternatives to the drug from the start.  Another is to limit the use of such drugs to only a short period of time. For this to work, education of everyone involved – doctors, dentists, patients — is critical. For example, Aetna has long had programs to educate dentists (who write one in every eight opioid prescriptions) about the dangers associated with opioids and other pain relief options.

There are enough prescriptions written each year for every man and woman in America to have a bottle of opioids.

More recently, Aetna’s Resources for Living, offered through its employee assistance program, has begun to help members manage and end their use of opioids. The education program encourages people to take the least amount possible for the shortest period of time necessary. It also prompts members to think about alternatives for pain relief. For example, a recent study found that mindfulness exercise was more effective than opioids in treating chronic back pain.

Sometimes the immediate danger of opioids lies not just in the drug itself, but also in the way it interacts with other drugs. In an effort to reduce that risk, Aetna watches its pharmacy claims for dangerous combinations of drugs.  For example, , because of complications arising from the way the medications interact, someone taking an anxiety medicine and an opioid could end up in the ER or worse. By setting up alerts in its pharmacy systems, Aetna strives to warn patients, pharmacists and prescribers.  Where possible, we attempt to do so before the patient walks out of the pharmacy with the second drug.

Step 2: Intervention 

One or two claims for an opioid are not typically a cause for alarm. On the other hand, when a patient receives multiple prescriptions, from multiple doctors or dentists, or is filling them at multiple pharmacies, the potential for misuse or abuse is far greater.  Aetna works to identify these latter scenarios, so red flags can be raised.

What happens next? That depends on the particular facts, such as how many prescriptions the member is filling. “If the member has filled prescriptions for four or more controlled substances within the same drug class, we send letters to the prescribers alerting them,” Dr. Un explained. “If the member continues to get more opioids, and especially if he is getting them from multiple doctors and multiple pharmacies, we’ll send letters to prescribers and the member, and call the prescribers to make sure they’re aware of the potential problem. We’ll refer the patient to a behavioral health specialist to help them quit the drugs. We can even deny the claim at the pharmacy if a member tries to fill another prescription, when that’s warranted.”

Aetna’s Special Investigations Unit is also often alerted when the Pharmacy area sees high volumes of opioid prescriptions being filled. While most opioid prescriptions and the pharmacies filling them are legitimate, Aetna can contact officials, such as regulators and law enforcement, if it sees evidence of illegal use or sale of prescription drugs.

Step 3: Treatment for opioid abuse

Sometimes people know they have a problem, but stigma keeps them from seeking treatment. Aetna is encouraging early treatment by reducing that stigma. It’s a founding member of the Campaign to Change Direction, which teaches the five sign of emotional suffering to help people recognize when they or someone else needs help. Aetna also offers Mental Health First Aid, an eight-hour program that teaches people how to identify and respond when someone is experiencing a mental health or substance abuse problem.

More than half a million Americans abuse heroin; most started out misusing prescription painkillers but turned to heroin because it was cheaper.

New approaches are also making inroads. Aetna and the Aetna Foundation collaborated to fund Narcan kits for law enforcement officers in Pennsylvania. In the past year, officers used the kits in more than 800 cases in to reverse overdose and potential death. Aetna also has integrated overdose screening into its behavioral health condition management program.

Aetna also has a program to provide care management to pregnant women on Medicaid with opioid addictions. The expecting mothers get treatment, and mother and child are followed by the same care manager for a year after birth to help them both stay healthy. In just the first six months of this program, Aetna saw neonatal intensive care unit admission rates drop by over 22 percent.

Step 4: Recovery

Substance abuse is a challenging condition to treat, with approximately half of the people who go through treatment relapsing. In an effort to reduce that number, Aetna continues to help find the most effective ways to help people recover. For example, Aetna is part of a research partnership funded by the National Institute of Drug Abuse that has almost doubled the use of medication-assisted treatment of substance abuse in Southeastern Pennsylvania and Maryland. In addition, we are working with organizations such as the National Institute of Drug Abuse, Ohio State Health University, University of California San Francisco and the University of Texas to study best practices in reducing the prevalence of drug abuse.

Once research has proven the effectiveness of different approaches, the next step is to encourage providers to use them. To that end, Aetna is beginning to develop value-based contracts with drug and alcohol rehabilitation centers, to promote such evidence-based approaches to substance abuse disorder.

Editor’s note: More information on the statistics cited above can be found at drugabuse.gov and the American Society of Addiction Medicine.