Pain Medications Revisited

The American Journal of Pharmacy Benefits, March/April 2016, Volume 8, Issue 2

Pain medication misuse in no longer just a medical issue alone, as payers need to consider their role and the actions they can take to address this problem.

Once again, pain medications are in the news. Not only are they appearing in medical journals, but they are also showing up in other “medical” publications such as The Wall Street Journal, USA Today, and The New York Times.

This is an important fact that should not be overlooked. Pain medication misuse in no longer a medical issue alone. It has become a societal issue.

You may remember that I recently wrote a column regarding the challenge of balancing the need to control a patient’s pain with being conscious of the risk of overuse and abuse.

So why am I once again writing about the topic of pain medications and opioid use?

As President Obama is looking to spend $1.1 billion in addressing the pain, opioid, and heroin epidemic, and CMS is considering a number of initiatives, it is important that payers (outside of Medicare Advantage) begin to do their part in addressing this crisis.

I have had a number of recent conversations with payers (both health plans and employers) about their role and the actions they can take to address this issue. If we are going to successfully begin creating a plan to address this difficult problem, we need to stop talking and begin acting. I believe that there are several steps that payers can take.

1. Payers are in a unique positon to be able to use data in order to identify those providers that participate in Centers of Excellence for Pain Management. In addition, payers need to identify providers that have been found to practice pain management outside of recognized guidelines. The payers need to direct and incentivize patients to providers with the greatest expertise and outcomes.

2. Payers should consider pharmacies for Centers of Excellence determination for dispensing of long-term pain medications. For the last several years, there has been a conversation occurring about where specialty medications should be dispensed due to the expertise and knowledge needed to best support the patients. I believe that payers should consider identifying certain pharmacies with long-term pain expertise as a similar support tool for these patients.

3. Payers should consider narrowing network plan design, not only for physicians, as discussed in the previous point, but also for both inpatient and outpatient drug rehabilitation services. Although mental health parity has improved coverage of services for drug rehabilitation, it has also brought a number of new facilities that have neither experience nor good outcomes associated with them.

Many payers have been reticent to create narrow networks for behavioral health, in general, and drug rehabilitation, specifically, due to mental health parity laws. What payers tend to forget is that if they have narrow networks associated with medical coverage, they should be able to have a similar plan design for behavioral health. The conversation regarding value-associated payments is one that has to extend to behavioral health, as it is part of the medical environment.

4. Payers need to consider drug testing as a companion test to long-term pain management use. I was surprised to find that there are a number of payers that do not cover opioid and pain medication testing. This reasoning behind this lack of coverage is unclear to me. I understand that there has been misuse of drug testing, just as there is of pain medications.

However, pain medications and testing both play very important roles in pain management. After speaking with well-respected pain management experts, it seems that monthly testing, or other scheduled pain medication testing, should be part of a long-term pain medication management regimen that payers should consider.

5. Payers should consider placing patients who are using pain management on a long-term basis in a medication therapy management (MTM) program. Pharmacists who have significant expertise in pain medications can often help to support both the patient and the physician. Historically, MTM has been utilized solely in the Medicare population. Payers should consider expanding the use of MTM programs for patients who are taking high numbers of medications or medications that can have significant negative outcomes.

We are at a point in time where we need to aggressively move forward in addressing the prescription pain medication crisis. This problem has significant impact across our country for patients, payers, and society as a whole.

Payers are in a unique position to take a leadership role in helping to frame a system that supports the appropriate use of pain medications, while also addressing those overutilizing, or at risk of overutilizing, pain medications.

What other ideas do you have? We all need to put our best ideas forward, and act.