Since 1999, over 760,000 people have died from drug overdoses—that’s one person every 16 minutes. Many of those drug overdose deaths are related to opioids. In fact, in 2020, 75% of overdose-related deaths involved an opioid. 1.6 million people had an opioid use disorder in 2019.
In addition to its devastating effect on human lives, the opioid crisis has cost billions to the U.S. healthcare system.
Since the opioid crisis was declared a public health emergency in 2017, healthcare organizations, government agencies, and health plans have implemented different opioid management programs to curb the epidemic, improve patient outcomes, and decrease costs.
In this article, we’ll discuss:
What is Opioid Medication Management?
The reckoning of the opioid crisis and its tragic consequences have led to a decrease in opioid prescribing. However, although opioids are no longer considered first-line treatment for pain conditions, many patients still need them.
As a result, these patients require opioid medication management.
According to the Centers for Disease Control and Prevention (CDC), managing opioids involves assessing the benefits and risks of prescribing opioids based on the patient’s life circumstances. For instance, can the patient’s age affect how they’ll respond to opioids? Do other medical conditions, e.g., kidney disease make them more at risk of experiencing opioid-related side effects? Does the patient have acute or chronic pain? Is the pain treated related to a medical condition like sickle cell disease?
Managing opioids also means considering and comparing non-opioid pain treatments before prescribing opioids. Common non-opioid pain treatments that can improve pain include serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressants, pregabalin or gabapentin, and nonsteroidal anti-inflammatory drugs (NSAIDs).
Managing opioids also includes evaluating opioid dose-dependent effects, like opioid misuse, overdose, increased risk of trauma, and death.
Managing opioids requires that the clinical team knows the patient’s medication history, including their history of controlled substances. This medication reconciliation process can happen through patient interviews and reviews of relevant prescription drug monitoring programs.
The Importance of Medication Management for Opioids
Economic burden of opioid mismanagement.
Data has shown that people with opioid use disorder (OUD) use significantly more healthcare resources, including emergency department visits, physician outpatient visits, and hospitalization. In 2014, an estimated 147,654 emergency department (ED) visits were due to opioid overdose, and they cost an estimated $152.8 million.
In a study published in Population Health Management, researchers found that compared to people without OUD, people with OUD had annual excess health costs from $14,054 to $20,54 and from $5874 to $15,183 for privately insured individuals and Medicaid-insured individuals respectively.
A report released by the Council of Economic Advisers (CEA) in 2017 estimated that the actual economic burden of the opioid crisis had been underestimated in previous data. The report estimated that the economic impact of the opioid crisis was $504 billion in 2015, mostly in mortality-related costs. This estimate also included healthcare-related costs, lost wages, and costs to the criminal justice system.
More recent reports from the PEW research center estimated that each year opioid misuse, dependence, and abuse cost $35 billion in healthcare costs, $14.8 billion in criminal costs, and $92 billion in lost productivity.
In a study published in the Journal of Managed Care Pharmacy, that looked specifically at the Medicare-insured population, researchers found that adjusted six-month healthcare costs were significantly higher for people with OUD versus people without OUD ($33,942 vs. $10,754).
Impact on health outcomes of opioid mismanagement
In addition to higher costs, opioid mismanagement has been linked to serious negative health outcomes.
A global estimate of opioid use and dependence found that in 2017, there were about 109,500 deaths related to opioid overdoses in the world, with 43% of these deaths happening in the United States.
A study published in the Journal of the American Medical Association (JAMA) looking at the outcomes of long-acting opioid use in Medicaid patients with chronic noncancer pain found that opioid use was linked to an increased risk for all-cause mortality. In this study, long-acting opioids were compared to analgesic anticonvulsants and cyclic antidepressants.
Opioid use is also linked to increased morbidity. For instance, a review published in the Journal of the American College of Cardiology found that chronic opioid use was associated with cardiovascular adverse events. People taking chronic opioids have an increased risk of myocardial infarction (MI) (1.28-fold; 95% CI: 1.19 to 1.37).
Another study specifically looking at the cardiac effects of opioid overdoses found that opioid-related overdoses were associated with ischemic events, heart failure, and arrhythmias.
Data has shown that people with OUD tend to have worse physical and mental health quality of life than the general population. OUD is also linked to a higher prevalence of medical complications, such as:
- Infections, such as cellulitis, wound botulism, necrotizing fasciitis, and endocarditis.
- Transmissible diseases, such as HIV/AIDS, hepatitis, syphilis, and tuberculosis
- Conditions related to heavy tobacco use, such as chronic obstructive pulmonary disease, hypertension, and coronary artery disease.
- Conditions resulting from intoxication or criminal activity, such as head trauma or gunshot wounds.
The longer an individual takes opioids, the higher their risk of experiencing opioid-related adverse events, like ED visits, hospital readmissions, and all-cause deaths. This risk also increases with higher opioid doses, above 90 morphine milligrams equivalent (MME).
Challenges to Implementing Opioid Medication Management Programs
With so much evidence already demonstrating the need for effective opioid medication management, one can wonder why more hasn’t already been done in that regard.
Healthcare Provider Challenges
One study published in the Journal of the American Board of Family Medicine identified several challenges to implementing opioid medication management.
Prescribers often have time constraints that limit how much time they can spend managing their patients’ opioids. The short visit time doesn’t always allow for a detailed medication and medical history.
Prescribers may feel that pain and opioid management take time away from managing other, less symptomatic, health conditions for those patients.
Frequent changes in insurance can also make it more challenging to manage a patient’s pain treatment, since different insurance plans may translate into different medication coverage and lead to a lack of care continuity. Lack of interoperability and data sharing between insurers further complicates opioid management as prescribers may not have access to claims or clinical records from the previous payer. Cash payments and prescriptions filled across state lines are often not accessible to prescribers, meaning prescribers never see the full picture of a patient’s fill history.
Lack of insurance coverage for nonpharmacologic treatments and limited access to integrative and specialty care can also make it challenging for prescribers to refer patients to non-opioid pain treatments.
Another crucial challenge regarding opioid management is the knowledge gap that exists about pain management pharmacotherapy. There is a shortage of pain management experts, and depending on their specialties, healthcare professionals (who are not experts on pain management) may have different levels of training and may lack understanding about different treatment uses and limitations.
One additional challenge for providers is recurrent drug shortages, which can make it harder to maintain continuity of care and can sometimes lead to abrupt treatment changes.
Finally, a lack of communication between the different stakeholders involved in managing opioids can be a great challenge. For example, providers seeing the same patient may not be able to communicate with each other except through electronic health records — if those are shared, which isn’t always the case. For Pharmacists, this means that when reviewing a patient’s medication history, they may not be able to communicate with prescribers if there’s an issue easily.
Patient Challenges
From the patient’s perspective, opioid management can be challenging due to the complex experience of pain. Each person’s experience of pain is subjective and unique, which means that there’s not a one-size-fits-all strategy for opioid management.
Plus people may use pain as a barometer of their healing, which may translate into high expectations regarding their pain treatment. These high expectations may make patients more resistant to trying non-opioid pain therapies.
In a study published in the British Medical Journal, the authors also referred to the lack of trust, communication, and empathy between patients and providers as possible barriers to effective opioid management.
Cost can also present a challenge for patients as they navigate changes in health plans or health/pharmacy benefit coverage.
Strategies for Opioid Medication Management
Different strategies can be used for opioid medication management.
Many opioid medication management strategies revolve around educational interventions. One study published in the Annals of Surgery found that sharing guidelines and information about overprescribing with providers was effective in decreasing the total number of opioid pills prescribed post-surgery by more than half (53% decrease).
In a similar study, authors shared with prescribers quarterly reports of their prescribing patterns, compared with their peers’ patterns. Providers also had access to educational opportunities about safe opioid prescribing. As a result, at the end of the 20-month study, the prescription rate of schedule II opioids was almost 20% lower than the rate at baseline.
Other strategies for opioid medication management include:
Opioid overprescribing has huge clinical and economic costs for both the lives of the patients involved as well as the overall healthcare system. But can opioid medication management significantly decrease these costs?
Potential Cost Savings from Opioid Medication Management
A study looking at the impact of a multidisciplinary pain management program found that the program was associated with a $754 reduction in the total cost of care per member per month (PMPM), including prescription medication costs.
Another study looking at the impact of a stepped-care approach found that people with musculoskeletal pain who first received manual therapy (before opioids) had a significantly lower day supply of opioids. They also had fewer opioid prescriptions (3.1 vs. 6.5) and overall they spent less in one year compared to people who received opioids as a first-line treatment ($10,782, vs. $11,938).
One English study looking at the impact of a digital pain medication program helping patients with their self-management skills found that patients engaged in the program had lower yearly healthcare costs (on average £240) compared to those who were not in the program.
In terms of opioid use disorder (OUD), a cost-effectiveness analysis published in JAMA Psychiatry found that medication-assisted treatment(using buprenorphine, methadone, or injectable extended-release naltrexone; psychotherapy; overdose education and naloxone distribution and contingency management) for OUD was associated with cost savings of $25,000 to $105,000 in lifetime costs per person
Improve Patient Outcomes with Opioid Medication Management
Besides potential cost savings, effective opioid medication management also has a positive effect on patient outcomes.
One study looking at millions of Medicare members found that prior authorization for prescriptions as a strategy for opioid management was linked to a decrease in opioid overdoses (3.3 fewer overdoses per 10,000 prescriptions compared to people filling an opioid not requiring prior authorization).
A modeling study published in the Lancet found that increased access to medications to treat OUD along with addiction consultation services could lower hospitalizations and overdoses by 5·2% and 6·6% respectively.
A study published in the Journal of the American Board of Family Medicine looked at the impact of pharmacists’ input to primary care providers on opioid prescribing. The authors found that the mean daily MME decreased by 14% when pharmacists reviewed patients’ charts before their doctors’ appointments and made recommendations to the provider. Meanwhile, patients didn’t experience any change in their pain scores.
Another study looking at the effect of a multimodal opioid medication management program on opioid prescribing found that after 16 months of intervention, the monthly MME per patient encounter was 58% lower than the average of the 6-month baseline. Additionally, the MME per opioid prescription per month was 34% less than at baseline, and the opioid prescription rate was 38% lower.
To see the effect at the population level that opioid medication management can have, one can look at the Opioid Initiative launched in 2015 by the state of Oregon in response to the state opioid crisis. The results of the initiative after two years were:
- A decrease of 37% in the number of Oregonians on 90 or more Morphine Equivalent Doses (MEDs).
- A 20% decrease in prescription opioid-related overdose deaths.
- A 27% decrease in Medicaid beneficiaries on 120 or more MEDs for 30 consecutive days.
Opportunities for Medication Intelligence to Aid in Opioid Medication Management
Medication intelligence using AI and predictive analytics provides new tools to support and scale opioid medication management for broader patient populations to improve patient outcomes and reduce the associated costs of care.
Arine’s platform enables identification and outreach to patients who may require opioid management in two different ways. First, the platform integrates diverse sets of data including clinical, pharmacy, behavioral health, social, and demographic data, and uses predictive analytics to determine which patients are at greatest risk related to their opioid use. This enables care teams to reach out to patients to focus their interventions on individuals at greatest risk. Secondly, the platform can be used to analyze prescribing patterns across a health plan’s prescriber population, to identify which prescribers may have multiple patients who might benefit from medication optimization. Using this approach, plans can have a broader impact by outreach to selected prescribers to impact their patient panels.
In addition to efficiently identifying patients requiring opioid medication management, Arine’s platform can also inform care teams and prescribers about the most impactful interventions to help each specific patient. The Arine platform not only identifies specific recommendations based on patient-specific care gaps but also prioritizes those actions to enable care team members and prescribers to have the greatest impact possible. For prescriber outreaches, Arine also provides valuable background information, based on patient-specific data and clinical guidelines, to support prescribers with the necessary clinical context for each intervention.
Finally, Arine’s platform enables efficient communication across prescribers and care team members as all clinicians involved with a patient’s care can communicate through the platform. Prescriber recommendations and patient care plans can also be directly shared through fax and email communications as needed.
Arine has helped multiple clients improve patient outcomes and reduce costs in their behavioral health populations, including patients requiring opioid medication management. One such client approached Arine to provide a scalable, provider-centric solution to impact member behavioral health outcomes and reduce total cost of care. Through Arine’s Prescriber Analytics program, the plan was able to have a positive impact on patient outcomes while reducing overall cost of care. Their results included a reduction in behavioral health polypharmacy by 45-55% and a lowering of their members’ MME by more than 60% for individuals taking 90 MME per day. Overall, the client was able to achieve overall cost savings of >$1,500 annual savings per engaged member per year in behavioral health spend.
Conclusion
Opioid misprescribing is linked to devastating consequences for patients and their families, such as increased incidence of opioid use disorder, overdoses, and avoidable deaths. It has cost the US hundreds of billions of healthcare dollars and lost productivity.
Opioid medication management can help improve patient outcomes and decrease costs.
Arine’s medication intelligence platform can “lift the horizon” and provide cross-system visibility and more efficiently identify people at risk of opioid-related complications and provide timely interventions for them and their providers.
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