Three out of every five Americans who use opiate painkillers use them in dangerous combinations with other medications, according to A Nation in Pain, a new comprehensive report on opioid trends in the U.S.
Particularly troubling about this trend:
- Two-thirds of these patients obtained opioid prescriptions from two or more physicians;
- 40% of these patients filled these medications at more than one pharmacy; and
- 8% were combining an opioid, muscle relaxant and benzodiazepine (for anxiety) – a popular combination among pill mills known as the “Houston Cocktail.”
While there are rare instances when prescribing an opioid in combination with a muscle relaxant or an anxiety medication is appropriate, these trends and patient behaviors are cause for concern and could signal potential abuse.
Devil Is in the Details
Treating pain is extremely challenging. Oftentimes, physicians are treating multiple related conditions that require prescription medications. As such, more sophisticated monitoring protocols – those that combine data resources, clinical expertise and technology – are needed to distinguish cases of abuse from legitimate patient care.
Forty-nine of the 50 States – Missouri being the lone exception – now have prescription drug monitoring programs (PDMPs) that include electronic databases of all prescriptions filled for controlled substances. However, these systems vary from state to state, and only 16 states require prescribers to use PDMPs when writing prescriptions.
Monitoring Works, but Enforcement and Collaboration Are Key
When utilized, properly resourced and consistently enforced, PDMPs can be highly effective in identifying and reducing cases of opioid misuse and abuse. For example, Tennessee saw a 47% drop in the number of people considered inappropriately “high utilizers” of opiate painkillers after implementing a law in 2013 requiring doctors to consult PDMPs before prescribing opioids to a new patient.
Collaboration with payers and benefit providers like Express Scripts can bolster the success of state programs with additional data and resources to identify cases of abuse, including patients who travel across state lines to obtain medications.
Express Scripts Fraud, Waste & Abuse team uses industry-leading, proprietary data analytics to uncover patterns of potential fraud or abuse, and scans for behavioral red flags to identify when someone is involved in wrongdoing. By combining the complementary capabilities behavioral sciences, clinical specialization and actionable data, our team has identified 290 potential indicators of pharmacy fraud.
Patient Review and Restriction Programs
People looking to abuse controlled substances often attempt to obtain prescriptions from multiple prescribers and to fill prescriptions at multiple pharmacies to avoid suspicion and make it more difficult to track their behavior.
The Patient Review and Restriction (PRR), or pharmacy lock-in, program is another effective approach taken by Express Scripts on behalf of state Medicaid plans and other payers to reduce opioid abuse. This program restricts certain patients to one pharmacy and, in some cases, to one prescriber for controlled substances and muscle relaxers.
A recent example of the impact of the Express Scripts PRR involves a patient identified through the Express Scripts Fraud, Waste and Abuse program. Before the PRR program was initiated, this patient had 38 claims for opiate pain medications between January 2013 and January 2014. After restricting the patient to the use of one pharmacy for filling prescriptions for controlled substances, the number of prescriptions dropped to 13, and spending on those medications went from a high of $92.82 per month pre-restriction, to a low of $2.93 per month post-restriction.
Impact of Express Scripts Patient Review and Restriction Programs
There are a number of highly effective programs and tools in place to prevent, identify and intervene in cases of prescription opioid abuse. But their success relies on the consistent application of necessary resources and enforcement. States can and should collaborate with payers and benefit providers, who can provide additional data and resources to identify cases of abuse. Working together, we can more efficiently and effectively identify abuse, and most importantly, help these patients obtain the necessary treatment to fight their addiction.
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