Seven things to know about Express Scripts’ plan to limit opioids

In the wake of President Trump declaring the opioid epidemic “a national emergency,” Express Scripts, the nation’s largest pharmacy benefit manager (PBM), has rolled out a new opioid management program that will limit the number and strength of opioid drugs to first-time patients.

According to the CDC, drug overdose is the leading cause of accidental death in the U.S., with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.

Express Scripts’ Advanced Opioid Management solution is expected minimize early exposure to opioids while helping prevent progression to overuse and abuse, while ensuring access to medication patients need.

In a pilot study, the PBM observed a 38% reduction in hospitalizations and a 40% reduction in emergency room visits after educating patients about the risk of opioid use. An educational letter was also sent out to providers who showed high prescribing patterns and held counseling calls. Among this subset, a 19% decrease in the day’s supply of opioid dispensing during six-months of follow up, was observed.

Meanwhile, the American Medical Association (AMA) has found fault with the program, saying that treatment decisions should be left to physicians and their patients.

Here are 7 things to know about Express Scripts’ program to limit opioids:

1.   It could create barriers to access for patients who may benefit from opioids. “While over-prescribing of some opioids is part of the problem, it risks introducing barriers to access for patients who may benefit from opioids, particularly those with long-term, chronic pain for which alternatives have not been adequate,” says Mark Sirgo, PharmD, president and CEO of BioDelivery Sciences. “In the case of Express Scripts and others, the restriction is specific to short-acting opioids.”

Sirgo

BioDelivery Sciences currently markets Belbuca (buprenorphine) buccal film (CIII), which contains buprenorphine and is considered a long-acting opioid, and thus is not impacted by these restrictions. As a Schedule III product, Belbuca results in a lower risk of abuse and addiction compared to the vast majority of opioids, which are Schedule II, according to Sirgo.

“While restricting access is one approach to managing the current opioid crisis, many healthcare providers consider buprenorphine to be an approach to treating chronic pain to delay or negate the need for Schedule II products,” he says. “Unfortunately, now we see a number of managed care plans that require the more addictive Schedule II products to be used prior to getting access to Belbuca or other buprenorphine products.”

2.   It relies on the expertise of the pharmacist. “Patients rely on doctors and doctors often rely upon the expertise of the pharmacists to help limit the deleterious effects of opioid prescriptive medication, which includes gastrointestinal [GI] bleeds, strokes, overdose death and risk of addiction,” says Stephani Higashi, DC, chief executive officer of the integrated healthcare practice HEALTH ATLAST. “Preventing these effects is cost saving and lifesaving. The cost of a lifetime of GI problems, overdoses or addiction is too costly to simply ignore and allow it all to continue.”

Higashi

Higashi hopes that these limitations will also open minds of doctors to provide patients other alternatives to pain management such as therapy, chiropractic, acupuncture, massage and nutrition as real solutions without the risk of addiction.

Michael Thompson, president and CEO of the National Alliance of Healthcare Purchaser Coalitions (formerly NBCH), shares a similar viewpoint. “The opioid crisis is a national emergency and pharmacy benefit managers are in a unique position in the system to identify where potential excesses are occurring. These efforts could be fundamental to identifying potential issues proactively and working with doctors and patients to curb them,” Thompson says.

Next: An inconvenience?

Runyon

3.   It may create issues or inconveniences for some doctors and their patients. “If we are going to call this an opioid epidemic then we need to begin changing how we respond to it,” says Kent Runyon, compliance officer and vice president of community relations for Novus Medical Detox Center. “We need to be clear that this single step will not significantly prevent the number of overdose deaths today. But if we combine actions such as this with other prevention and treatment efforts, we will begin to see change. People need increased access to quality individualized care. Systems of care need better skills and attention on prevention. We have a very long way to go.”

Along the lines of concerns by the AMA, Gregory Makris, MD, medical director, Center for Appropriate Care, Altarum Institute, believes that medical decisions are kept in doctors’ hands and “avoid blanket policies as a substitute, as that’s more or less how we got here in the first place,” Makris says. “Physician autonomy is an important principle of the practice of medicine, and there are tools-such as prescription drug monitoring programs with reports, focused training and CMEs-that can provide feedback and on-going training to clinicians to help them create the best practice patterns possible.”

4.   It shows that all stakeholders need to do their part. “Express Scripts can’t do it alone,” Thompson says. “We need to look at every part of the system, including surgeries that could be done with a less intense regimen of pain medications and better outcomes. It’s going to require all stakeholders including health plans, providers and employers to do their part to turn the tide on this crisis.”

5.   It will force prescribers to think differently about how they manage patient pain for non-palliative and non-cancer patients. “U.S. consumers need to look at opioids differently and seek alternatives to them,” Runyon says. “We all need to request alternative approaches from our medical providers when possible. The U.S. consumes 80% of the world's supply of opioid medication while we only make up 5% of the globe’s population. We must change or this epidemic will continue to take its toll.”

Barrington

6.   Similar efforts may be rolling out. Priority Health supports Express Scripts’ efforts in helping to control the opioid crisis and is also committed to reducing the number of members experiencing opioid-related overdose or death, according to Christina Barrington, vice president of pharmacy programs, Priority Health.

In fact, Priority Health is rolling out a similar initiative designed to reduce opioid use by 25% within the next three years. “This will be accomplished through a multipronged approach of education, proactive outreach and policy changes that will focus on reducing the number of short-acting dose units prescribed, increasing the number of members in substance-abuse treatment programs, and reducing the number of members receiving prescriptions from multiple providers,” Barrington says.

7.   It puts the focus on education. “The danger of limiting opioids is the risk that the epidemic could become worse if patients seek ‘street’ alternatives, exposing them to far more dangerous counterfeit opioids, tainted drugs, or heroin,” says Naomi Lopez Bauman, director of healthcare policy at the Goldwater Institute.

Lopez Bauman

“While well-intentioned, solutions that interfere with the practice of medicine and potentially contribute to the needless suffering of patients are perilous prescriptions,” Lopez Baumann says. “Current efforts should focus on harm reduction, educating doctors about recognizing and managing patients who might be in trouble, and educating the public about treatment options.”