State Efforts to Combat Opioids

8/18/2019 State Efforts to Combat Opioids

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State Efforts to Confrontthe Opioid Epidemic

April 13, 2016

Allan Coukell, BSc PharmSenior irector, !ealth Pro"rams#he Pe$ Charita%le #rusts


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#he Pe$ Charita%le #rusts


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!o$ Pe$ &orks

Pew is an independentnonproft, nonpartisanresearch and policyorganization

Tools:

Research

Partnerships

Technical assistance

Advocacy


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Pro'ect Philosoph(

Clear need or action

Solid evidence about thecause o the proble

!illingness by iportantconstituencies to act

A way or Pew to adduni"ue value

Reasonable odds ortangible progress


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Pe$)s Current Priorities

5

#eocracy

Religion

Arts and culture

$nvironent

State policy

Consuer protection

Public opinion anddeographics

Health care

Sae ood and drugs

Patient care

Antibiotic resistance

%ioedical science

Substance use disorders


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Pe$ Efforts on Su%stance *se isorders

1) Reduce the inappropriate use of prescription drugs while ensuring

that patients with legitimate medical needs have access to effectivepain control, and

2) Advance federal and state reforms that improve the effectiveness oftreatment for alcohol and opioid use disorders through increased useof medication-assisted treatment.


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State Efforts to Confront Opioid Epidemic

Todays discussion will cover si! themes"

1) #tates roles in su$stance a$use prevention and treatment

2) %rowing momentum for state action

&) 'edication-assisted treatment

() arity

5) *arm reduction

+) fforts to deter and identify misuse and a$use


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Opioid Epidemic+ Burden of isease


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State oles in Com%atin" the Epidemic+-undin"


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State oles in Com%atin" the Epidemic+Su%stance *se isorder A"encies


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State oles in Com%atin" the Epidemic+.edicaid and the ACA

rior to the AA, most state 'edicaid programs did notcover childless adults and covered only a limited num$erof parents

overage of su$stance a$use services has traditionally$een an optional 'edicaid $enefit and many states haveprovided only limited su$stance a$use service coverage.

/early 12 percent of 'edicaid $eneficiaries over 10 havea #


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State oles in Com%atin" the Epidemic+.edicaid and the ACA


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/ro$in" nterest in #acklin" theEpidemic at the State eel

231+ state of the state addresses covering su$stancea$use" Ari4ona, lorida, 6ndiana, 'assachusetts,'issouri, /ew 7ersey, 89lahoma, :ermont, and ;est:irginia

/ational %overnors Association has $een assistingstates in developing tailored responses to the epidemic<this year they made recommendations for federal actionto support states


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State #ask -orces to Address OpioidOerdose

6ndiana 'aryland

'ichigan

/ew =or9

ennsylvania

Rhode 6sland

:irginia


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.assachusetts Opioids e"islation


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.edicationAssisted #reatment


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*ighly effective"

6llicit opioid use is reduced $y (3-B3 percent onaverage

Ris9 of *6: infection is reduced si! fold and ris9 ofinfection with hepatitis and ? drops

'ethadone decreases opioid overdose $y (3-03percent

mployment increases

Reduced criminal activity


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:ia /ora :ol9ow, /ational 6nstitutes on rug A$use


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C 23D of people with an opioid use disorder receive treatment inany given year


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emand E4ceeds Capacit( for.edicationAssisted #reatment

emand far e!ceeds capacity

7ones, ', et al. /ational and #tate Treatment /eed and apacity for 8pioid Agonist 'edication-AssistedTreatment.American 7ournal of u$lic *ealth" August 2315, :ol. 135, /o. 0, pp. e55-e+&.


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Case Stud(+ 5ermont !u% and Spoke

%oal is to enhance the provision of 'AT forindividuals with opioid addiction

*u$" Regional specialty addictions treatmentcenters regulated as opioid treatment programs and

operated $y community $ehavioral health agencies

#po9e" Teams of health care professionals led $yphysicians who prescri$e $uprenorphine in

practices


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#ource" /A#AA 2315 Annual 'eeting, :T 'edicaid claims

Case Stud(+ 5ermont !u% and Spoke


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Criminal 'ustice

iversion rug courts

'AT

Return to the community

Eegal Action enter " http"FFlac.orgFwhat-we-doFsu$stance-useFparityF and http"FFlac.orgFresourcesFsu$stance-use-resourcesFparity-health-care-access-resourcesF


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Parit(+ A e$ -rontier

The 2330 federal 'ental *ealth arity and AddictionGuity Act @'*AA) prohi$its discrimination in healthinsurance coverage of su$stance use disorder andmental health $enefits

lans su$ect to the federal parity law are precludedfrom providing these $enefits in a more restrictive waythan other covered medical $enefits

#tates are primarily responsi$le for monitoring and

enforcing the federal parity law for group and individualmar9et coverage

Eegal Action enter " http"FFlac.orgFwhat-we-doFsu$stance-useFparityF and http"FFlac.orgFresourcesFsu$stance-use-resourcesFparity-health-care-access-resourcesF


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!arm eduction+ alo4one

#ource" /etwor9 for u$lic *ealth Eaw

8pioid antidote, also9nown as /arcan

'ore than 153,333people receivednalo!one 9its from

community outreachprograms,1HH+ and231(

'ore than 2+,333overdoses were

reversed using those9its, according to the


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!arm reduction+ eedle E4chan"e

hoto" #eth *erald for /R

6ndiana reversed $an in response to spi9e in *6: cases tied toopioid a$use

Ientuc9y also passed legislation allowing local health departmentsto run programs


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!arm eduction+ Safe n'ection Sites

hoto" The Associated ress

/o safe havens for inecting illegal drugs e!ist in the #, $utit is $eing considered in some states, such as A and '


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State Efforts to eter and dentif(

.isuse and A%use

atient Review and Restriction rograms

rescription rug 'onitoring rograms

'ethadone for ain ontrol


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&hat is a Patient eie$ and

estriction Pro"ram 7P89

rograms that 'edicaid and private insurance plans use to identifyand manage patients at-ris9 for prescription drug a$use

lan identifies a patient receiving large Guantities or duplicativeopioids from multiple prescri$ers or pharmacies

atient is reGuired to use a designated pharmacy andFor prescri$er too$tain controlled su$stance prescriptions

RR programs can improve continuity of care

atient protections ensure access to pain medicine while lowering the

ris9 of overdose


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efinin" isk for Opioid Oerdose

=ang J, et al J Pain. 2315


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P &id l * d i . di id


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Ps are &idel( *sed in .edicaid

Pro"rams


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States Structure their .edicaid

Ps in One of #hree &a(s

www.pewtrusts.orgFRRreport


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.ore than !alf of .edicaid Ps o otOffer Beneficiaries Additional Serices



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.ost .edicaid Ps o ot !ae Access to theState Prescription ru" .onitorin" Pro"rams



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.edicaid P Pro"ram Outcomes

> T/" decreases in controlled su$stance use when comparing prior to and atleast si! months after RR enrollment

51 percent decrease in pharmacies visited

&& percent decrease in prescri$ers visited, and

(+ percent decrease in num$er of paid prescriptions

> '/" estimated cost savings of K1.2 million in the first year of patient enrollment

Reductions in prescriptions, emergency room utili4ation, and clinic visits

Average savings of K(,033 per patient

> 8I" decreases in pre- and post- enrollment in the mean monthly average for"

/arcotic prescriptions @from 2.1+ to 1.&2),

mergency department visits @from 1.2+ to 3.01),

/um$er of pharmacies visited @from 2.35 to 3.0H), and

/um$er of prescri$ers seen @from 2.(0 to 1.+&)


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Prescription ru" .onitorin"Pro"rams 7P.Ps8

rescription rug 'onitoring rogram Training and Technical Assistance enter, L' Eegislation M 8perational ates,Nhttp"FFwww.pdmpassist.orgFcontentFpdmp-legislation-operational-dates


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LO's are unli9ely toreach their full potential inreducing prescription

drug misuse and a$useand diversion if they arenot utili4ed.N

Office of National DrugControl Policy, 2015

https"FFwww.whitehouse.govFsitesFdefaultFfilesFondcpFpolicy-and-researchF2315PnationalPdrugPcontrolPstrategyP3.pdf


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Optimi:in" Prescri%er *tili:ation ofPrescription ru" .onitorin" Pro"rams

nsolicited Reporting

rescri$er se 'andates

elegation ata Timeliness

#treamlined nrollment

ducational and romotional 6nitiatives *ealth 6nformation Technology 6ntegration

nhanced ser 6nterfaces


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Availa$le at http"FFwww.pdmpassist.orgFpdfFrescri$ersP#olPnsolPReports.pdf

. h tt ) A t f


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.assachusetts) Assessment of*nsolicited eportin"

'A adopted electronic alerts in ecem$er 231& 6nitial results" >21 percent of prescri$ers who received an alert logged

into the ' for the first time >5H percent of patients who were the su$ect of an alert

sent the first month did not meet the threshold again forthe ne!t si! months

>rescri$er survey @n Q 0B) 8nly 2( percent were aware of all other prescri$ers providing

controlled su$stances to their patients

05 percent said viewing ' data increased confidence inprescri$ing decisions

http"FFwww.pdmpe!cellence.orgFsitesFallFpdfsF'AD23'D23electronicD23alertD23/.pdf


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.andator( P.P *se

Availa$le at http"FFwww.namsdl.orgF6ssuesandventsF2315D23AnnualD23ReviewD23ofD23rescriptionD23'onitoringD23rogramsD23graphics.pdf


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*niersit( of ;entuck( Ealuation of.andate #hrou"h One


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eports e=uested ;entuck( P.P+200> throu"h 201>

I study availa$le at" http"FFwww.chfs.9y.govFosFoigFIA#R.htm

http://www.chfs.ky.gov/os/oig/KASPER.htmhttp://www.chfs.ky.gov/os/oig/KASPER.htm


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e$


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< State+ .ultiple Proider Episodesand P.P eport e=uests

ote+ 'ultiple provider episodes defined as patients using five or more prescri$ersand five or more dispensers within the month. Source+ /ew =or9 '

October 2011 - December 2015

Patients &eeting &ultiple

Provider $pisode

Threshold

P#&P Report Re"uests

Number of Patients Meeting Multiple Provider pisodes !hresholdNumber of PDMP "eport "e#uests


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Provision for Prescriber Delegates

#elegates can obtain P#&P reports or prescribers, whenstate law perits'

Prescribers set up subaccounts

Prescribers can audit delegates( use'

Prescribers are accountable or delegates( use'

All states with coprehensive prescriber use andatesperit delegates'

As o )*+, -* states perit delegates'


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.a'or P.P -undin" .echanisms

%rants > ederal @?ureau of 7ustice Assistance, enters for isease ontrol

and revention)

> rivate @/ational Association of #tate ontrolled #u$stances

Authorities)

#tate general revenue funds

Regulatory $oard funds

Eicensing fees > ontrolled su$stance registration fees

Availa$le at http"FFwww.pdmpassist.orgFpdfF'PundingP8ptionsPTA%.pdf


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.ethadone


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.ethadone

A synthetic opioid that has $een used since the 1H+3s to treatheroin addiction $y mitigating withdrawal symptoms1

6n the mid-1HH3s, methadone $egan to $e increasingly prescri$ed

for the treatment of chronic noncancer pain1

Accounts for ust two percent of opioid pain reliever prescriptions,yet is implicated in nearly one third of these deaths2

1 enters for isease ontrol and revention, L:ital #igns" Ris9 for 8verdose from 'ethadone sed for ain Relief > nited #tates, 1HHH>2313,N Morbidity and MortalityWeekly e!ort +1, no. 2+ @2312)" (H&-(HB, http"FFwww.cdc.govFmmwrFpreviewFmmwrhtmlFmm+12+a5.htm2 enters for isease ontrol and revention, L:ital #igns" rescription ain9iller 8verdoses" se and A$use of 'ethadone as a ain9iller,Nhttp"FFwww.cdc.govFvitalsignsFpdfF2312-3B-vitalsigns.pdf


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&h( s .ethadone Still Prescri%ed for Pain9

actors that may $e driving use include"1,2,&

Eong duration of action

ffective treatment for refractive pain

ost differential

'ethadone is a preferred pain reliever for most state 'edicaidprograms.(

> &3 states currently list methadone as a preferred analgesic for pain5

.1 ood and rug Administration, L'ethadone *ydrochloride Approved Ea$el (F1(F231(,Nhttp"FFwww.accessdata.fda.govFdrugsatfdaPdocsFla$elF231(F3H3B3B8rig1s33&l$l.pdf 2.The American Academy of ain 'edicine, LThe vidence Against 'ethadone as a Sreferred Analgesic" A osition #tatement rom the American Academy ofain 'edicine,N http"FFwww.painmed.orgFfilesFthe-evidence-against-methadone-as-a-preferred-analgesic.pdf &.,L8verdose eaths 6nvolving rescription 8pioids Among 'edicaid nrollees;ashington, 233(-233B,N MMW, 50, no (2 @233H)"11B1-5( , L:ital #igns" rescription ain9iller 8verdoses" se and A$use of 'ethadone as a ain9iller,N http"FFwww.cdc.govFvitalsignsFpdfF2312-3B-vitalsigns.pdf5. The ew harita$le Trusts, in-house research on state 'edicaid fee-for-service preferred drug lists

2


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Strate"ies *sed %( State .edicaid


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Strate"ies *sed %( State .edicaidPro"rams to Address .ethadone Safet(

Remove methadone from the preferred drug list @E) > 6n 231&, /orth arolina $ecame the first state to remove

methadone from its E1

> ..2 and 13 other states followed

%ive methadone non-preferred status on drug lists

> !amples" Alas9a,& 'innesota,( /evada,5 Tennessee,+ ;est:irginiaB

1 :estal , L'ost #tates Eist eadly 'ethadone as a Sreferred rug,N "tateline, Apr. 2&, 2315, http"FFwww.pewtrusts.orgFenFresearch-and-analysisF$logsFstatelineF2315F(F2&Fmost-states-list-deadly-methadone-as-a-preferred-drug2 istrict of olum$ia. 'edicaid referred rug Eist, Availa$le at https"FFdc.fhsc.comFdownloadsFprovidersFR!PEPlisting.pdf & Alas9a 'edicaid referred rug Eist, Availa$le at http"FFdhss.alas9a.govFdhcsFocumentsFpdlFF2315-E-RAT.pdf ( 'innesota 'edicaid referred rug Eist, Availa$le at http"FFwww.dhs.state.mn.usFmainFidcplgU6dc#erviceQ%TP6EMRevision#election'ethodQEatestReleasedMRenditionQrimaryMallow6nterruptQ1Mno#aveAsQ1Mdoc/ameQdhsPidP31+H225 /evada 'edicaid referred rug Eist, Availa$le at https"FFwww.medicaid.nv.govFownloadsFproviderF/:PEP23153131.pdf + Tennessee 'edicaid referred rug Eist, Availa$le at https"FFtenncare.magellanhealth.comFstaticFdocsFreferredPrugPEistPandPrugPriteriaFTennarePE.pdf B ;est :irginia 'edicaid referred rug Eist, Availa$le at http"FFwww.dhhr.wv.govF$ms&FharmacyFocumentsF;:D23E31202315D23v2315D232e.pdf

Strate"ies *sed %( State .edicaid


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6mplement prior authori4ations > !amples" 'assachusetts1 M elaware2

6ntroduce stepped therapy

> !amples" 8hio&

rovide education to improve use

> !ample" ;ashington #tate conducted outreachwarning lettersand office visits to educate top prescri$ers a$out pharmacology.(

1 'assachusetts 'edicaid referred rug Eist, Availa$le at https"FFmasshealthdruglist.ehs.state.ma.usF'*EFpu$downloadpdfcurrent.doUidQ(52 elaware 'edicaid referred rug Eist, Availa$le at http"FFwww.dmap.state.de.usFinformationFharmacyF'D23E.pdf & 8hio 'edicaid referred rug Eist, Availa$le at"http"FFmedicaid.ohio.govFortalsF3FrovidersFroviderTypesF'edicaidrugrogramFharmacyandTherapeuticsommitteeF231(-3B-2H-Erevised.pdf ( :estal , L'ost #tates Eist eadly 'ethadone as a Sreferred rug,N "tateline, Apr. 2&, 2315, http"FFwww.pewtrusts.orgFenFresearch-and-analysisF$logsFstatelineF2315F(F2&Fmost-states-list-deadly-methadone-as-a-preferred-drug

Strate"ies *sed %( State .edicaidPro"rams to Address .ethadone Safet(

Documents

State Efforts to Combat Opioids