Update, Sept. 6:
BlueCross has announced additional policy changes for opioids, which take effect Jan. 1, 2019. See our press release for details.
Original story, Feb. 23:
Opioid misuse, abuse and addiction has been declared a public health emergency, and few states have been hit as hard as Tennessee. The state currently ranks third in the nation for opioid prescribing and fourth for overdose deaths.
We sat with Natalie Tate, PharmD, vice president of pharmacy management at BlueCross, to discuss the epidemic, its impact on our members and how BlueCross is working to turn the tide.
What led to this nationwide epidemic?
Dr. Tate: The roots stem back to the mid to late 1990s, when marketing of pain medications grew and they were being touted as not posing a risk for addiction. Additionally, around that same time pain became a measure used as part of overall hospital accreditations. As part of a survey process, patients began to be asked how well their pain was being managed. That, combined with a lot of new pain medications such as OxyContin coming to market, resulted in much more use and prescribing of these agents as a response.
“There was never any ill intent by providers. I don’t believe anyone truly understood the potential of these medications for abuse and addiction at that time.”
We became a society that was being prescribed and using a lot more of these medications. We moved away from understanding that pain is a natural response to indicate when something is wrong. That led to more and more prescribing. By not understanding the power of these medications, in terms of their addiction potential, we ended up with people becoming addicted.
What factors led to Tennessee having the second highest opioid prescription rate?
Dr. Tate: There are many manufacturing jobs in our state, and this type of work can lead to pain. These medications were more frequently prescribed starting in the mid ’90s and throughout the 2000s. Tennessee has not always been equipped with programs to help people move away from these medications, or have hard discussions with people about these drugs. That’s one reason we’ve had such a high prescribing rate – and subsequently, such a high death rate – from these products. There may not be alternative therapy options, such as physical therapy, especially for someone in a rural part of the state.
When did BlueCross begin to address the opioid epidemic?
Dr. Tate: Our efforts in the opioid space began in 2013 and were focused on babies with neonatal abstinence syndrome. Many mothers, particularly in the Upper Cumberland/East Tennessee region of the state, had been using opioids during pregnancy, and babies were born dependent. There are many adverse effects associated with that.
From there we stepped up our education efforts within our provider community, asking what their opioid prescribing looked like and helping them recognize the domino effect associated with these prescriptions.
There’s no silver bullet to fix this epidemic. In 2014 BlueCross said, “We’re going to treat this as a true epidemic, and tackle it from a variety of perspectives.” That includes providers, our charitable giving, looking at how we cover opioids and what opioids we cover, etc. There’s a lot of community involvement and awareness, getting the word out about this being an epidemic, and having discussions around opioid use and abuse. These are topics that traditionally people have hesitated to discuss.
How are we measuring our efforts’ success?
Dr. Tate: We look at different metrics. For example, from the community awareness perspective, Count It! Lock It! Drop It! measures the poundage of opioids – and any other medication – collected across the state.
From a prescription drug perspective, we are looking at volume. Long-term, we plan to look at morbidity and mortality. For 2017, we saw a 6 percent reduction in the number of opioid prescriptions used. We’ve also seen a 52 percent reduction in the use of long-acting opioids – typically prescribed for chronic pain – due to our prior authorization requirement, and a 2 percent reduction in short-acting opioid use – typically prescribed for acute pain – as well as lower strengths being used. This is important from a safety perspective.
Last year saw a nearly 194,000 decrease in the number of opioid prescriptions overall compared to 2016. That’s about 12 million fewer pills in the hands of our members.
Those are just some raw numbers. Overall we’ve seen positive results, but we have to do more.
If someone is prescribed an opioid, what questions should they ask their physician or pharmacist?
Dr. Tate: Questions should start at the physician office. We are all responsible for asking our physicians questions. I know people can be a little shy or afraid to do so, because they don’t want their doctor to think they’re questioning his or her expertise. That’s not what this is; you need to ensure you’re well informed about your medications. Anytime you get a medication, lots of questions should be asked, but especially for something that has a potential for abuse, misuse or addiction.
“If you’re prescribed an opioid, the first question to ask your physician is ‘Why do I need this?’ followed by ‘How long do I need to take this?’”
Other important questions to ask are:
- “What types of side effects can I have from this medication?”
- “How will this medication impact other diseases that I may have?”
- “How many of these do I really need?”
- “Do I need to take this on a schedule, or is it just as needed?”
- “How do I know when I need to take this medication?”
- “Will this medication interact with other medications I’m taking?”
- “Are there medications I can take in place of opioids?”
When you see your pharmacist, ask him or her these same questions.
What resources do we provide members who struggle with opioid use?
Dr. Tate: Members can reach out to us and ask “What benefits do I have that can help me?” There may be other medications. There may be detox and inpatient/outpatient programs. There may be counseling options, depending on your particular health plan benefits. BlueCross can provide a list of things that, based on your plan, are covered as part of these services.
For example, medication-assisted treatment – sometimes referred to as MAT – is prescription drugs you can take instead of opioids. They provide pain relief, but they will not give you that feeling of euphoria, which is what so many people become addicted to.
Chronic pain is a very real condition that often requires an opioid prescription. Is there guidance BlueCross provides to help ensure proper adherence?
Dr. Tate: In 2017 we began ensuring that people with chronic pain, who are taking long-acting opioid medications, are receiving proper doses and have been through proper screenings, based on guidelines from the Centers for Disease Control and Prevention and the Tennessee Chronic Pain Guidelines.
We want to ensure providers are starting with, and continuing, the right dose. We want to ensure people are not getting a dose that could result in death or adverse events. This was added to our prior authorization review process for medications for chronic pain.
We realize that members see that as a barrier, but we’re doing it from a safety perspective. We want to ensure our providers are not starting somebody with a dose that’s very high, or keeping them at a high dose, when studies show that over certain doses, you’re not getting extra pain control.
What advice would you give families who fear a member is struggling with addiction?
“Addiction is a side effect of a medication. It’s not a sign of weakness. These medications are extremely powerful. Even within a few days, you can start having that addictive potential.”
The first piece is having that conversation, bringing up the awareness. Many times people might not even realize that they’re becoming addicted, but somebody else may see it. The observations that warrant a discussion are:
- “You say you’re not in pain, but you keep taking these pills.”
- “You say you’re still in pain, but you don’t want to go back to the doctor because you’ve still got pills. You’re taking them on a much shorter schedule.”
- “You’re watching the clock to see when you can take your next medication.”
How will our opioid efforts continue in 2018?
Dr. Tate: From a prescription perspective, and for safety reasons, we’re looking at potentially reducing quantity limits for members who have pharmacy benefits. Additionally, we’re looking at targeted outreach efforts for some of our newer members, particularly in the Knoxville area as we have re-entered the ACA Marketplace there.
Internally, a lot of work between medical management and behavioral health is helping us identify people with chronic conditions who also have high opioid use. How can we educate that population?
We’re also looking at targeted outreach to providers. For example, we want to determine how many have members who have received a prescription from a dentist’s office.
We’re also going to continue collaborating with partners in the community and in government.
What’s the most important takeaway regarding this epidemic?
Dr. Tate: The opioid epidemic in Tennessee, and in the country, didn’t happen overnight. And we’re not going to solve it overnight. As an insurer, we have a role to play, but this is much bigger than just BlueCross. It is a public health initiative. This is going to take everyone, and discussions need to be ongoing. We are committed to doing our part to facilitate those discussions.