Every year, the Centers for Disease Control and Prevention (CDC) analyze and
highlight the states with the highest rates of overdose-related deaths. States
with significant increases in deaths due to drug overdoses were mainly in the
Northeast and South Census Regions.1,2 In response, many federal and
state agencies have released guidelines to address this growing opioid
epidemic, and Independence has updated our opioid management strategy.
Recommendations from federal and state-level
opioid guidelines3,4
In 2013, the Centers for Medicare & Medicaid Services (CMS) initiated the
Overutilization Monitoring System (OMS) to monitor patients with the following
criteria:
- use more than 120 MED* for at least 90 consecutive days;
- see more than three prescribers;
- go to more than three pharmacies.
As a result of the OMS?s interventions, CMS reported a 47 percent decrease
in Part D beneficiaries overutilizing opioids (based on the above criteria)
from 2011 to 2015. Since the initiation of OMS, CMS has recommended a threshold
limit of 120 MED. The OMS showed that the threshold limit of 120 MED was a
sensitive marker to assess the risk of opioid-related death and identify
overutilizers.
Other federal and state-level agencies have followed the CMS recommendation
and created their own threshold limits. The CDC supported using a threshold
limit of 90 MME* for all opioid users in its 2016 guidelines. Based on a
systematic review of different trials, the CDC found evidence that discouraged
prescribing 90 MME or more.
Updates to Independence?s opioid management
strategy
As a key stakeholder in the opioid epidemic, Independence has enhanced our
opioid management strategy for 2017. Below is an outline of some of the updates
that will apply to our commercial and consumer business (non-Medicare), which
include the utilization management that will be used by Independence in an
effort to encourage appropriate prescribing of opioids. According to CDC
researchers, the probability that an opioid-naive patient would become a
chronic opioid user increased sharply after as little as five days of
use.5 The updated management strategy uses the 90 MME* threshold
identified by the CDC in an effort to encourage appropriate use of prescription
opioids for acute or chronic pain.
Opioid management for acute
pain
- Prior authorization is required for the following:
- – all opioid products whose standard dosing exceeds 90 MED*;
- – all opioid patches (as of July 1, 2017);
- – most strengths of long-acting opioids.
- Effective July 1, 2017, Independence will implement a
cumulative five-day supply per 30-day period for members newly
initiated on an opioid (i.e., have not received an opioid within the last 30
days). If additional days? supply is required, a prior authorization will be
needed. This applies to:
- – all opioid products whose standard dosing is ? 90 MED* (e.g., ? 10
mg oxycodone IR);
- – all opioid-containing cough and cold products;
- – all butalbital products.
Opioid management for chronic
pain
- A Patient-Provider Agreement is required. You can view samples of a Patient-Provider
Agreement online.
- Prior authorization is required annually.
Medication Assisted Treatment (MAT) for
opioid addiction
- As of May 1, 2017, prior authorization was removed from all
buprenorphine/naloxone products (i.e., Zubsolv®,
Bunavail®).
- Effective July 1, 2017, buprenorphine products are
available without prior authorization for a cumulative 180-day supply per
rolling 365 days. A prior authorization must be requested if additional days?
supply is needed within one year.
- Prior authorization is required when an opioid is filled within two months
of a paid claim of a buprenorphine-containing MAT (e.g., Bunavail
®, Suboxone®, Zubsolv®,
Subutex®).
For additional information on Substance Use Treatment Programs, members can
refer to the mental health/substance abuse telephone number on the back of
their ID card.
*The following acronyms are used to define the total
daily dose of opioid converted to morphine equivalents: MED: Daily morphine
equivalent dose in milligrams; MME: Morphine milligram equivalents per day;
OME: Oral morphine equivalents per day.
1Rudd RA, Seth P, David F, Scholl L.
?Increases in drug and opioid-involved overdose deaths-United States,
2010-2015.? Centers for Disease Control and Prevention Morb Mortal Wkly
Rep. Accessed March 21, 2017. Available from: www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm.
2Centers for Disease Control and
Prevention/National Center for Health Statistics. ?Drug overdose death data.?
2013 [updated 2016 Dec 16; cited 2017 Apr 21]. Available from: www.cdc.gov/drugoverdose/data/statedeaths.html.
3Centers for Medicare & Medicaid
Services. ?Analysis of proposed opioid overutilization criteria modifications
in Medicare Part D.? 2017. Available from: www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrug
CovContra/Downloads/Proposed-Opioid-Overutilization-Criteria-Modifications-v-020
12017.pdf.
4Dowell D, Hagerick TM, Chou R. ?CDC
guideline for prescribing opioids for chronic pain?United States, 2016.?
JAMA. 2016;315(15):1624-45. Available from: http://jamanetwork.com/journals/jama/fullarticle/2503508
.
5Walker, Molly. ?Longer Initial Opioid
Prescription Ups Risk of Chronic Use.? MedPage Today. March 26, 2017.
Available from: www.medpagetoday.com/PainManagement/PainManagement/63888?xid=nl_
mpt_DHE_2017-03-17&eun=g807263d0r&pos=2.