Use of controlled substances is an essential part of the prescription drug regimen for many members. However, these medications come with an increased potential to adversely affect both members and plan sponsors. Unlike other categories of medications, inappropriate use of controlled substances has the potential to compromise member safety, increase potential for addiction and diminished quality of life, increase the risk of workplace injuries, and increase the chance for diversion. These effects may result in poor health outcomes, an increased risk of complications, and a negative impact from a cost and mortality perspective.
Per the National Institute on Drug Abuse, every day, more than 90 Americans die after overdosing on opioids.1 The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare. Serve You Rx launched the Opioid Risk Management Program to address the crisis of abuse and addiction, and the associated problem of rising costs, by reducing the likelihood of misuse through a multitude of proactive and retrospective approaches.
The Opioid Risk Management Program begins proactively at the point of prescribing and dispensing, including application of quantity limits, conducting point-of-service drug utilization review, and prior authorization. The Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) have taken steps to quantify member opioid use and cumulative dosage points at which member safety and abuse start to compromise appropriate use of opioids. The Serve You Rx Opioid Risk Management Program uses this information to apply member safety checks during the prescribing and dispensing of opioid prescriptions.
Retrospective review of opioid prescribing patterns, dispensing patterns of pharmacies, and member utilization further helps to tackle this crisis through awareness and education using real life data. The goal of the Serve You Rx retrospective DUR program is to minimize the occurrence of drug abuse, diversion, and inappropriate use of high-risk medications, as well as to identify at-risk members and provide their healthcare providers with comprehensive information to enable the providers to initiate appropriate medical intervention. On a quarterly basis, reports are reviewed by a clinical pharmacist to identify members receiving multiple controlled substance prescriptions and/or using multiple prescribers or pharmacies to determine if prescriber or dispensing pharmacy intervention is warranted.
Increased costs are a natural consequence of opioid misuse. The CDC estimates that the total “economic burden” of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.2 While the number one priority of Serve You Rx’s Opioid Risk Management Program is to improve member health, the downstream effect of cost savings can be achieved by instituting strategies such as formulary management and step therapy that manage utilization, and ultimately, risk.
1 Rudd RA, Seth P, David F, Scholl L. Increases in Drug and
Opioid-Involved Overdose Deaths — United States, 2010–2015.
MMWR Morb Mortal Wkly Rep. 2016;65. doi:10.15585/mmwr.
2 Florence CS, Zhou C, Luo F, Xu L. The Economic Burden of
Prescription Opioid Overdose, Abuse, and Dependence in the
United States, 2013. Med Care. 2016;54(10):901-906. doi:10.1097/