It is a tragic case of unintended consequences. An opioid painkiller formulated to prevent drug abuse has altered, rather than stopped, the way addicts get their high – and among the results are new outbreaks of HIV and hepatitis C.
From Southern Indiana to Massachusetts, and across rural Appalachia, health officials are facing exponential increases in the spread of these diseases among abusers who share needles to inject crushed opioid tablets. Across Central Appalachia, for example, officials tracked a 364% increase in Hepatitis C cases between 2006 and 2012 – and that same region has one of the country’s worst problems with opioid abuse.
The Path to Addiction
Nearly 45% of young injectors are estimated to be infected with Hepatitis C.
While there are many contributing factors to addiction, and to what drives a person to take such risky behaviors, for many the path starts with prescription drugs. A study by the Massachusetts Department of Public Health looked at new Hepatitis C infections among people aged 15 to 24 over a seven-year period, and found that most had started opioid abuse with oral oxycodone about 12 to 18 months before transitioning to injecting heroin.
Some pharmaceutical companies responded by reformulating painkillers in ways that make them more difficult to crush and inject. These new pills came to market as branded medications, commanding much higher prices than the generics they sought to replace. And yet they have not always succeeded in preventing abuse.
In particular, Opana® (oxymorphone) still can be injected. When crushed and mixed with water, it becomes sticky and too thick to inject with the most common needles – but is injectable with larger needles that are harder to come by and thus more often shared. Opana also contains more fillers and has a shorter half-life in the body than other traditional painkillers, so the high from an injection doesn’t last as long and abusers tend to inject themselves more times each day.
Rampant Spread of Hepatitis C and HIV
Southeastern Indiana has seen one of the fastest-spreading recorded outbreaks of HIV in the U.S., and it is being driven by Opana injections, according to the National Institute on Drug Abuse, an arm of the National Institutes of Health. Most of those infected with HIV also are co-infected with Hepatitis C, according to the Centers for Disease Control and Prevention.
These tragic outcomes are spurring action in the public and private sectors.
Indiana Gov. Mike Pence issued an executive order in March declaring a public health emergency over the spread of HIV. He temporarily suspended laws that made nonmedical uses of injection needles a felony, allowing clean needle distribution to help slow the transmission of disease.
The Need for Proactive Solutions
Health officials nationwide have been calling for increases in health care, support programs and other care for opioid drug abusers.
There also is a role that insurance providers can play. Innovative tools used in the pharmacy benefit, in particular, can address opioid abuse early – before patients progress to using heroin or crushed and injected pills.
Express Scripts is launching a proactive opioid education pilot that uses advanced data analytics to identify – at the first fill of an opioid medication – members who may be at higher risk of prescription drug abuse. In these instances, we will send out educational materials about side effects, safe handling and storage as well as the risks of dependence.
In addition, for the next six months after a first fill we will monitor patient claims data to spot signs of potential risky behaviors that would trigger a call from one of our specialized neuroscience pharmacists to the patient for proactive counseling.
Express Scripts also has very powerful data analysis and reporting tools that allow us to flag situations that could indicate abuse, whether in the actions of physicians, pharmacies, or patients. Our Fraud, Waste and Abuse solutions help us identify doctors who are prescribing many more opioids than their practice would warrant, “pill mill” pharmacies that are filling them, and patients who may be drug seeking by visiting multiple doctors and pharmacies across a larger than expected geography.
Our MediCUBE® tool integrates medical and pharmacy claim data, giving us real-time access to more than 15 billion records that we use as the foundation of this diagnostic system.
When we find an outlier – a doctor, pharmacy, or patient behaving in ways we would not expect and that could indicate opioid drug abuse – we flag the case for our clients who provide the pharmacy benefit. We are exploring whether we can directly take action to stop abuse, for example by limiting a patient’s opioid prescriptions to a single provider and pharmacy and referring them for counseling.
Stopping the problem is important. Preventing it from occurring is an even more impactful opportunity. We can and should do more to prevent opioid drug abuse and the unfortunate resulting spread of HIV and hepatitis C.
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