Bridging the Gap Between Opioid Policy and Prescribing

State and federal governments have taken legislative action to reduce the harm caused by the opioid epidemic, including preventive activities aimed at influencing prescriber behavior, as well as working to intervene when opioid use becomes problematic.

An influx of recent legislation has been passed to fight the opioid epidemic, and current legislative trends focus on two fronts. One approach seeks to prevent opioid misuse through prescriber education and the use of prescription limits to lower the quantity and duration of opioid prescriptions. The other front assists those who suffer the long-term effects of opioids, primarily by expanding access to opioid overdose drugs and drug treatment programs for opioid dependency.

Avoiding the long-term prescribing of opioids altogether would be a big step in reducing the damage caused by these products, and there have been many different legislative movements employed to influence prescribers’ opioid prescription patterns.

THE DEA LOWERS OPIOID MANUFACTURING QUOTAS

As part of a larger initiative to decrease production among Schedule I and II substances, the Drug Enforcement Administration (DEA) has reduced the amount of nearly every Schedule II opioid that may be manufactured in 2017 by 25% or more.¹ Some opioids face even bigger decreases in manufacturing quotas, such as hydrocodone, which is expected to see a 66% decrease.

How Can This Help?

Theoretically, fewer opioids means fewer people can be impacted by their adverse effects, but some argue these reductions merely target a pre-existing excess of opioids that, even when counting inappropriate prescriptions, were more than enough to supply the demand for opioids. Such critics claim that this change will result in little-to-no direct impact on prescriber activity.

However, this action does send prescribers a powerful message, making it clear that there are too many opioids available, demanding more scrutiny for opioid therapy, and reiterating the need for caution and education. It is a good initial step that further echoes the demand of other legislation that also call for safer opioid prescribing.

MANDATORY PDMP QUERIES

Forty-nine states currently employ prescription drug monitoring programs (PDMPs) that record, monitor, and evaluate data for certain prescription drugs in order to better regulate them. While PDMPs have primarily operated on a voluntary basis, some states have passed legislation requiring physicians to query a PDMP when prescribing opioids.

At the end of 2015, 15 states required prescribers to check PDMPs prior to starting opioid therapy (not including Washington state, where this rule applies only to workers’ compensation),² and in 2016, Maryland, California, and New Mexico joined those states after passing similar laws (with California’s law targeting all Schedule II-IV drugs, including opioids).^3-5

Some states have passed laws requiring prescribers to check PDMPs before prescribing opioid prescriptions greater than certain lengths of time, ranging from three days to 30 days, and states such as Pennsylvania and Massachusetts have passed laws where all opioid prescriptions require a PDMP check.^6-7

IN 2016, THE CENTERS FOR DISEASE CONTROL AND PREVENTION GAVE 29 STATES A TOTAL OF $30 MILLION DOLLARS TO IMPROVE PDMPS.⁸

How Can This Help?

Mandatory PDMP queries require prescribers to take an additional step before writing the first and sometimes subsequent prescriptions. This PDMP check increases visibility into questionable patient behaviors, such as a history of seeking early refills, or the presence of multiple prescribers and/or pharmacies. These indicators may cause the prescriber to reconsider opioids, request the patient submit to a urine drug screen, or employ an alternative therapy.

This leads to increased patient safety, as well as significant cost savings from avoiding the complications that can accompany opioids. According to data collected from 2004-2014 by the National Survey of Drug Use and Health, mandatory PDMP programs have been shown to reduce doctor shopping for pain medications by 80%.⁹ Many individual states have seen positive outcomes as well due to their PDMPS.

In Ohio, a 20% decrease in opioids dispensed was credited to their PDMP,¹⁰ while New Hampshire attributed a 10% decrease in Schedule II pain relievers to their PDMP.¹¹ Furthermore, 50% of prescribers who changed their prescribing patterns in Indiana credited their change to their state’s PDMP,¹² and 43% of prescribers in Tennessee are less likely to prescribe controlled substances after checking PDMPs.¹³

OPIOID PRESCRIPTION LIMITS

In March of 2016, Massachusetts became the first state to limit initial opioid prescriptions, restricting them to a seven-day supply.⁷ In the months thereafter, New York, Maine, and Connecticut followed suit,^16-18 while Rhode Island implemented a morphine milligram equivalent (MME) limit of 30mg a day for a maximum of twenty doses.¹⁹

Other states such as Alaska and Delaware proposed similar laws last year just before state legislative sessions ended across the nation. As legislative sessions began earlier this year, similar bills have come forward. New Jersey recently passed a five-day opioid prescription limit,²⁰ while Ohio and Utah have passed seven-day limits,^21-22 and (as of this writing) Maryland, Indiana, Oregon, Washington, and Hawaii have expressed interest in a seven-day limit,^23-27 and North Carolina has introduced legislation aiming for a five-day limit.²⁸

How Can This Help?

Opioid prescription limits are intended to limit opioid prescribing to the short-term phase, discouraging chronic use that leads to adverse effects such as respiratory depression, high morphine equivalent dose (MED) levels, and an increased risk of dependence and misuse. These laws also encourage more interaction between patients and prescribers, allowing prescribers to better monitor opioid therapy and identify more intervention opportunities.

DENYING OPIOID PAYMENTS THAT DON’T FOLLOW EVIDENCE-BASED GUIDELINES

In early October of 2016, Ohio initiated new a rule in the workers’ comp setting that only allows opioids to be reimbursed in the workers’ comp setting if they follow best medical practices, which would include an individualized treatment plan, risk assessment, and close monitoring of patient progress.²⁹

Vermont initiated a similar rule in November, allowing workers’ comp payers to deny payment for opioids that do not follow treatment guidelines,³⁰ and now New Jersey is interested in enacting a similar rule.³¹

States like New York and Minnesota have already implemented similar legislation in the past, while other states include such opioidrelated rules within their formularies, such as Texas and Washington, with California soon to join them. As the effects of the opioid epidemic continue to show themselves, it is likely more states will push for treatment that falls in line with evidence-based medicine.

How Can This Help?

Encouraging the use of evidence-based medicine has been shown to cause prescribers to adjust their prescription behavior.³² Furthermore, legislation that calls for increased communication and patient monitoring may also lead to improved care. Guidelines may require that patients be made more aware of the risks associated with opioid therapy, and close patient monitoring prompts prescribers to further scrutinize their patients’ progress with opioid therapy, which could lead to discontinuation or weaning.

21ST CENTURY CURES ACT

In December 2016, President Obama signed the 21st Century Cures Act. The act impacted many different long-reaching healthcare initiatives, but among them it allocated $1 billion to help fight the opioid epidemic.³³

The funds will be divided equally between 2017 and 2018, granted to individual states for the following purposes:

• Improving state PDMPs
• Implementing activities that prevent opioid abuse, as well as evaluating how effective those strategies are
• Training healthcare professionals on opioid best practices, pain management, and more
• Any other appropriate public health activities related to addressing the opioid epidemic

How Can This Help?

The funds from this act can strengthen current initiatives that show promise, while also supporting the creation of new opioid prevention strategies that may filter into workers’ compensation.

Furthermore, evaluating the effectiveness of opioid prevention strategies will inform stakeholders on which strategies do and do not work. This allows resources to be devoted to more efficient strategies and programs, avoiding wasted effort and leading to the highest possible patient safety improvement, which would also lead to cost savings.

RESTORATION LEGISLATION:
WORKING BEYOND OPIOID PREVENTION

While it is best to prevent patients from experiencing the adverse effects of opioids in the first place, it is still important to have a plan in place for when opioid use grows problematic. Key legislation has increased access to treatment for opioid dependence while also expanding efforts to counteract opioid overdose, hoping to help patients struggling with opioids.

CONGRESSIONAL ACTION

21st Century Cures Act³³

$1 billion approved to fight the opioid epidemic with grants that:

• Train healthcare professionals to recognize signs of substance abuse
• Support access to healthcare services for opioid-use disorders
• Improve opioid overdose prevention

The Comprehensive Addiction and Recovery Act (CARA)³⁴

• $25 million granted to expand access to medication-assisted treatments for opioid dependency
• $25 million granted to expand access to naloxone, the opioid antidote that reverses opioid overdoses, as well as increased naloxone training and education

STATE ACTION

• 47 states have expanded access to naloxone, the opioid antidote that reverses overdose and saves lives³⁵
• The New York Workers’ Compensation Board will allow insurers to request special hearings to determine if injured workers be weaned off opioids³⁶
• Massachusetts will fast track certain opioid-addicted injured workers to a voluntary mediation program designed to wean them off opioids³⁷

THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

• $11 million provided to 11 states to expand access to medicationassisted treatment services for persons with opioid-use disorders³⁸
• $11 million provided to 12 states to reduce opioid overdoserelated deaths³⁸
  • Funds the purchase and distribution of naloxone
  • Supports training on overdose prevention
• Increased access to buprenorphine, a drug used to treat opioiduse disorders
  • Qualified prescribers may prescribe buprenorphine to 275 patients, an increase from a 100-patient limit, assisting more people suffering from opioid dependence³⁹
  • Nurse practitioners and physician assistants may prescribe buprenorphine after initial training, further increasing access to opioid-dependence treatment³⁴

MAKING LEGISLATION WORK FOR COMP

As workers’ comp professionals continue to fight for education, awareness, and evidence-based medicine, it is often the enacting of legislation that empowers these practices at various stages of opioid therapy. It is therefore crucial that payers, PBMs, and other workers’ compensation stakeholders not only follow opioid legislation as it develops, but that they be involved in the development of legislation that seeks to improve patient outcomes.