Transcript New Directions Behavioral Health - Mid

Opioid Misuse: An Employers Path Forward
August 25, 2016
1
Overdose deaths per 100,000
2003-2014: County level data
Image Source: NYT adaptation of data from “Drug Poisoning Mortality: United States, 2002–2014” by Lauren M. Rossen, Brigham Bastian, Margaret Warner, Diba Khan and Yinong Chong,
and from the National Center for Health Statistics, Centers for Disease Control and Prevention, accessed via http://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-inthe-us.html?_r=0 on May 3, 2016
9
Why Should Employers Care?
•
Big Money: In 2014, opioid-related absenteeism and presenteeism costs U.S. Employers
an estimated $10 Billion ($1.71 pmpm)
•
Higher Utilization: these Employees cost almost 2x as much in healthcare expenses
than similar, non-abusing individuals
•
Disproportionate Drivers of Healthcare Costs: opioid-abusers make up only 4.5% of
those with an Rx, yet drive 40% of all opioid spending and 32% of all Rx’s written
•
National Epidemic Drivers: opioid abuse costs the U.S. economy approx $56 Billion
in 2015
Source: NBGH, Castlight, Integrated Benefits Institute, National Center for Health Statistics, CDC Wonder
OPIOID MISUSE:
WHAT EMPLOYERS
CAN DO
METHODOLOGY
•
Primary source of information: medical and prescription claims
reporting
•
Opioid prescriptions analyzed across demographic categories and
2015 annual medical healthcare spending
•
Analyses restricted to de-identified and aggregated prescription
opioid claims received between 2011 and 2015.
•
“Abuse” was defined as meeting the following conditions:
— Receiving greater than a cumulative 90-day supply of opioids
— Receiving an opioid prescription from four or more providers over
the five-year period between 2011 and 2015
Confidential
29
KEY FINDINGS
Research on opioid abuse in the workplace provides employers with a
more accurate picture of the extent and depth of this ongoing crisis:
PRESCRIPTIONS
MEDICAL SPENDING
AGE
One out of every three (32%)
opioid prescriptions is being
abused.
Opioid abusers cost
employers nearly 2X as
much in healthcare expenses
on average than nonabusers.
Baby boomers are 4X more
likely to abuse opioids than
Millennials.
INCOME
Individuals living in
America’s lowest
income areas are 2X
as likely to abuse
opioids as those living
in the highest income
areas.
BEHAVIORAL
HEALTH
Patients with a behavioral
health diagnosis of any kind
are 3X more likely to abuse
opioids than those without
one.
PAIN
GEOGRAPHY
Opioid abusers have 2X
as many pain-related
conditions as nonabusers.
Opioid abusers
are more likely to
live in the rural
South than in
other regions.
Confidential
18
KEY FINDINGS: PRESCRIPTIONS
One out of every three (32%) opioid prescriptions is being abused.
Percent of opioid
prescriptions
received by abusers
32%
4.5%
Percent of individuals
who received an opioid
prescription that are abusers
Percent of opioid
prescription spending
attributed to abusers
40%
Confidential
19
KEY FINDINGS: MEDICAL SPENDING
Opioid abusers cost employers nearly 2X as much ($19,450) in healthcare
expenses on average annually as non-abusers ($10,853).
The difference in
total medical costs
for 2015 between
opioid abusers and
non-abusers
Confidential
20
KEY FINDINGS: AGE
Baby boomers are 4X as likely to abuse opioids as Millennials.
Age
group
Relative share
of abusers (%)
Abuse
rate (%)
0-19
0.3%
0.1%
20-24
1.9%
1.0%
25-29
3.3%
1.8%
30-34
6.2%
2.9%
35-39
7.8%
3.8%
40-44
10.2%
4.7%
45-49
13.0%
5.8%
50-54
17.7%
7.1%
55-59
17.6%
7.4%
60-64
13.6%
7.3%
65+
8.4%
8.9%
Millennials
2.0%
Baby
Boomers
7.4%
Confidential
21
KEY FINDINGS: INCOME
Individuals living in America’s lowest income areas are 2X as likely to
abuse opioids as those living in the highest income areas.
Relative share of abusers (%)
26.3
24.8
21.3
14.8
12.8
Lowest (less than $40,000)
Low ($40,000 - $48,000)
Middle ($48,000- $60,000)
Abuse rate (%)
High ($60,000 - $84,000)
Highest (greater than $84,000)
6.3
5.7
4.7
3.3
2.7
Confidential
22
KEY FINDINGS: BEHAVIORAL HEALTH CONDITIONS
Individuals with a behavioral health diagnosis of any kind are 3X more
likely to abuse opioids than those without.
8.6%
3%
Percent of people, with a
behavioral health diagnosis,
abusing their opioid
prescription
Percent of people, without a
behavioral health diagnosis,
abusing their opioid
prescription
Confidential
23
KEY FINDINGS: PAIN-RELATED CONDITIONS
Opioid abusers have 2X as many pain-related conditions as non-abusers.
Age group
Relative share of
abusers (%)
Abuse rate (%)
Joint pain
43.4%
14.6%
Neck pain
34.2%
12.6%
Abdominal pain
16.1%
11.7%
Back pain
77.1%
11.3%
Arthritis
28.9%
11.0%
Fracture
35.9%
9.4%
Nephrolithiasis
(Kidney stones)
9.9%
9.4%
Cholelithiasis
(Gallstones)
6.6%
9.0%
Sickle cell
0.4%
8.6%
62.4%
8.3%
Non-fracture injury
58.9%
7.1%
Dental/jaw pain
7.0%
7.0%
Pelvic
18.6%
6.4%
Chest pain
Note: The abuse
rate is defined as
the share of
prescription holders
that abuse.
Confidential
24
Employers Path Forward
Top 10 Recommendations for Preventing, Mitigating and
Providing evidence-based treatment for people living with
addition to opioids
Recommendation #1: Introspection
1. Refrain from Judgement – Compassion Over
Conviction
•
Addiction IS NOT a moral failure. It is a medical issue plaguing our nation that requires
Compassion rather than conviction. Partnering with a Behavioral Health partner is an important
step in the right direction.
31
Recommendation #2: Analyze Prescription
Opioid Related Claims
2. Work with your PBM and health plans to analyze
prescription opioid-related claims.
•
Look at claims data to identify opioid prescription trends and opioid-related health care use in
your population. Identify patients with multiple prescriptions and multiple opioid-related
emergency room visits and hospitalizations.
31
Recommendation #3: Employee Education
3. Educate employees, and cover and/or require
alternative pain management options.
•
Promote educational resources like Consumer Reports Health’s Surprising Things You Need to
Know About Prescription Painkillers and Avoid Opioids for Most Long-Term Pain.
•
Encourage alternative approaches to pain management, including lifestyle adjustments,
behavioral therapy, acupuncture and massage. The Business Group’s resource, Non-Invasive
Treatments for Low Back Pain provides several examples on page 4.
•
Consider reducing cost sharing on alternative pain management therapies for patients with a
history of addiction or opioid abuse.
32
Recommendation #4: Health Plan Outreach to
Providers
4. Encourage your health plans and hospitals to conduct
provider outreach on appropriate opioid use.
•
Health plans should contract with providers who agree to be follow new CDC guidelines
on opioid prescribing.
•
Health plans can help implement physician decision-support tools that help providers make
evidence-based decisions about pain management.
•
Identify providers whose high prescription rates – this may indicate inappropriate
prescribing. Your PBM and health plan should contact high prescribers to discuss appropriate
vs. inappropriate opioid use.
33
Recommendation #5: Utilization Management
5. Implement prior authorization, step therapy and
quantity limits.
•
Step therapies should require documented pain evaluations and non-opioid and
generic treatments before covering opioids for long-term chronic pain.
•
Quantity limits (e.g. only reimbursing for a limited number of pills per prescription fill) reduce
the likelihood that patients will stockpile medication, whether intentional or not.
•
Ensure that dispensing pharmacies cannot override rejected claims without a doctor’s
requested exception.
34
Recommendation #6: Use Formularies that
Promote Safe and Efficient Painkillers
6. Work with your PBM to craft formularies that
promote safe and efficient painkillers.
•
One formulary strategy prioritizes the use of generic prescription opioids, instead of highercost brand-name medications.
•
Alternatively, you can use your formulary to promote the use of new abuse-detterrant
formulations (ADFs) that prevent some methods of opioid abuse. They do not fully remove the
ability to abuse the drug, but they make it more difficult.
•
Talk to your PBM about excluding coverage of new powerful and long-acting oral opioid
therapies that have raised concerns from public health and health care professionals.
35
Recommendation #7: “Lock-in” and Opioid
Medication Agreements
7. Consider implementing “lock-in” and opioid
medication agreements for high utilizers.
•
Consider a “lock in” policy for individuals suspected of “doctor-shopping.” This requires them
to use a single pharmacy and/or single prescriber for prescription opioids.
•
Employers may ask patients to commit to following their physician’s care plan for chronic use
of opioids prior to filling a prescription by having them sign a patient contract.
36
Recommendation #8: Safe disposal of unused
pills.
8. Encourage employees to safely dispose of
unused pills.
•
Promote the safe disposal of unused medications to prevent children, pets or others without a
prescription from ingesting them.
•
Support pharmacy medication take-back programs that allow people to return unused
medications to some of their locations. Connect employees to local governments that run waste
management and law enforcement, as many of them run medication disposal programs as well.
37
Recommendation #9: Access to mental health
services and employee assistance programs
9. Implement robust access to mental health services
and employee assistance programs (EAPs).
•
Create robust networks of behavioral health providers to help plan members who struggle with
addiction to opioids and other substances to receive evidence-based services. As heroin use
increases, it is critically important to not just prevent the abuse of prescription opioids, but help
individuals who become addicted, sometimes via legitimate prescriptions.
•
Communicate the importance of addressing mental health needs, especially around major
health conditions or “episodes” (e.g. surgery.) Stress, mental illness, alcohol abuse and long-term
post- surgical recovery can contribute to patients becoming dependent on prescription
painkillers.
•
Encourage employees to take advantage of an EAP that offers counseling and/or screening
from a specialist provider who can help monitor the employee’s drug use and offer resources to
help with their addiction, including connecting them to appropriate providers.
38
Recommendation #10: Act Now!
10. See It, Own It, Solve It, Do It!
•
Once A Leader KNOWS MORE; they MUST DO MORE! Act now in pulling together your
Integrated Health Management Team and confirm your next steps.
36
Additional Resources
NBGH: Preventing Opioid Misuse and Abuse
NBGH: Evidence-Based Treatments for Low Back Pain Castlight
Health: The Opioid Crisis in America’s Workforce Consumer
Reports: 5 Surprising Facts on Prescription Painkillers Consumer
Reports: Avoid Opioids for Most Long-Term Pain
Office of National Drug Control Strategy: 2015 National Drug Control Strategy
CDC: Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
Pew: Curbing Prescription Drug Abuse With Patient Review and Restriction Programs
National Safety Council: The Proactive Role Employers Can Take: Opioids in the Workplace
National Safety Council: Prescription Pain Medicines: A Fatal Cure for Injured Workers
Troy Ross
President & CEO
www.machc.org
@MidAmHealth
www.linkedin.com/in/Troy-Ross
Appendix
36
Understanding the Epidemic
•
•
•
•
•
•
•
6
More people died from drug overdoses in 2014 than in any year on
record.
The majority of drug overdose deaths (more than six out of ten)
involve an opioid.
And since 1999, the rate of overdose deaths involving opioids
(including prescription opioid pain relievers and heroin) nearly
quadrupled.
From 2000 to 2014 nearly half a million people died from drug
overdoses.
78 Americans die every day from an opioid overdose.
Since 1999, the amount of prescription opioids sold in the U.S.
nearly quadrupled, yet there has not been an overall change in the
amount of pain that Americans report.
Deaths from prescription opioids—drugs like oxycodone,
hydrocodone, and methadone—have also quadrupled since 1999.
Image Source: June 4, 2015 cover of TIME Magazine, accessed via http://time.com/3908684/in-the-latest-issue-34/ on May 3, 2016
Statistics Source: “Drug overdose deaths in the United States hit record numbers in 2014,” accessed via
http://www.cdc.gov/drugoverdose/epidemic/index.html on May 3, 2016
What Are Opioids?
•
•
•
•
7
Hydrocodone (e.g., Vicodin)
Oxycodone (e.g., OxyContin, Percocet)
Morphine (e.g., Kadian, Avinza)
Codeine
Definitions
8
Abuse
Taking any substance, including a prescription drug,
for recreational purposes (i.e., to get “high”)
Misuse
Taking any medication not as prescribed (i.e., twice a
day when the prescription says once a day)
Diversion
Unlawful channeling of a regulated pharmaceutical
from a legal source (intended patient) to an illegal
source (giving to a friend, relative, neighbor, etc., or –
more overtly – selling for profit)
National Overdose Deaths
Number of Deaths from Rx Drugs
30,000
Total
Female
Male
25,000
20,000
15,000
10,000
5,000
0
Source: National Center for Health Statistics, CDC Wonder
National Overdose Deaths
Number of Deaths from Prescription
Opioid Pain Relievers
20,000
Total
Female
Male
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Source: National Center for Health Statistics, CDC Wonder
National Overdose Deaths
Number of Deaths from Benzodiazepines
9,000
Total
Female
Male
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Source: National Center for Health Statistics, CDC Wonder
National Overdose Deaths
Number of Deaths from Cocaine
8,000
Total
Female
Male
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Source: National Center for Health Statistics, CDC Wonder
National Overdose Deaths
Number of Deaths from Heroin
12,000
10,000
8,000
6,000
4,000
2,000
0
Total
Female
Male
National Committee on
Evidence-Based Benefit Design
The National Committee on Evidence-Based
Benefit Design seeks to:
•Identify solutions to help employers align plan
design, communications, and health programs
with available clinical evidence.
•Ensure employees are incentivized to seek
appropriate, high quality care.
The Committee meets twice a year in Washington,
DC, bringing together large employers, clinical
leaders, and strategic partners. Membership is
free to employers.
4