Opioids in Workers’ Compensation: PBM Solutions

1. Opioids in Workers’ Compensation: PBM Solutions

2. The material in today’s presentation is based on the training and professional experience of the presenters, and is not intended to represent the opinions or policies of the City of Denver or Midwest Employers Casualty Company.

3. Ray Sibley • Director of Risk Management • City and County of Denver • Marcos Iglesias MD, MMM, FAAFP, FACOEM • Medical Director • Midwest Employers Casualty Company • Broad WC experience as treater, medical director, PBM director and others

4. What to Expect • A review of the opioid problem in WC • Latest developments - Zohydro ER, Moxduo CR • PBM as gatekeeper • Opioid strategies • Patient opioid education as part of the strategy • What to look for in a PBM

5. Opioids • Opium (1500 BC) • Morphine (1804) • Codeine (1832) • Heroin (1874) • Dihydrocodeine (1908) • Oxycodone (1916) • Hydrocodone (1920) • Hydromorphone (1924) • Methadone (1937) • Fentanyl (1960) • Tramadol (1977) • Buprenorphine (1980) • Oxycodone ER (1996) • Zohydro ER (March 2014)

6. Daily MED • Morphine equivalence dose (MED) • Fentanyl 100X more potent than morphine • 10 morphine • = 10 hydrocodone • =7 oxycodone • = 70 codeine

7. Scope of the problem • 254 M opioid prescriptions: Enough to “medicate every American adult around the clock for a month” • 16,500 deaths from overdose • More than for all illegal drugs combined • 285% increase (2000 – 2010) • 32 ED visits for adverse effects per death CDC, 2011

8. Costs: WC

9. Costs: WC • Use of a short acting opioid: 3X cost • Use of a long acting opioid: 9X cost • Older claims: up to 40% of medical cost NCCI, 2011

10. Costs: California Off work 3.6X longer 60% higher litigation rates Claim costs 2X more expensive WCRI, 2013

11. Adverse effects • Itching • Nausea/Vomiting • Drowsiness • Euphoria • Constipation • Bowel obstruction • Depression • Addiction • Immune system • Endocrine system • Decreased sex drive • Hyperalgesia • Respiratory depression • Death

12. Safety: MED • Many have chosen 120 mg as a “red flag” • Washington State: 120 mg • Connecticut: 90 mg • Ohio: 80 mg • ACOEM Opioid Guidelines (2014): 50 mg

13. Safety: Other drugs • Central nervous system (CNS) depressants Alcohol Benzodiazepines Sedatives

14. Evidence for use • Little-to-none • Short-term studies (1 to 4 months) • Most are funded by industry • High dropout rates • Studies exclude patients with mental and substance abuse disorders

15. Zohydro ER • Zogenix, Inc. • Extended release pure hydrocodone – no APAP • No abuse deterrent properties • Capsules: 10, 15, 20, 30, 40 and 50 mg • AWP $7.02 to $8.58

16. Zohydro ER • Black Box Warning • Abuse potential • Life threatening respiratory depression • Accidental fatal overdose, esp. in children • Potential for neonatal opioid withdrawal syndrome • Avoid alcohol

17. Zohydro ER: Concerns • Do we need another opioid? • No abuse deterrent properties • Under the direction of Dr Margaret Hamburg the FDA went against its own advisory committee recommendation (11 to 2) when it approved Zohydro ER

18. Zohydro ER: Clinical Trials • 302 subjects randomized to Zohydro ER or placebo • 12 weeks • Looking for 30% reduction in pain • 67.5% vs. 31.1%

19. Other • Purdue developing an extended release hydrocodone to compete with Zohydro ER • Moxduo CR • Combination morphine – oxycodone • Rejected last week by an FDA advisory committee

20. Multi-stakeholder solutions

21. PBM: Gatekeeper • Formulary design • Step therapy • Real-time DUR (prospective) • Prior authorization process • Drug review (retrospective) • Monitoring and identification of risk • Data • Education

22. Formulary • Right drug for the right patient • List of drugs that will be automatically filled • State specific • Acute vs chronic • Injury specific • Claimant specific

23. Step therapy • Requires the use of a certain drug before escalating to another, more expensive or dangerous drug

24. Drug utilization review (DUR) • Correct doses • Early refills • Duplicate fills • Quantities • Dangerous combinations • Multiple or unauthorized prescribers or pharmacies • Formulary • Step therapy

25. Prior authorization • Rx at pharmacyTriggerRejection • P/A alert to payerDecisionAction • Time-sensitive • Requires knowledge on part of the adjuster

26. Time sensitive Avoid frustration at pharmacy Avoid use of a third party payer • P/A to NCM or UR department? • Is the p/a alert truly real time? • Is it batched (30+ minute delay)?

27. Knowledge and decision support Adjusters are not pharmacists or clinicians Educational and informational support Internal (NCM, MD, UR) and external Does the PBM help the payer make a good decision?

28. Prior authorization • BENEFITS: • Multiple user roles streamline the process • Team collaboration • Increased efficiency for nurses who data sift for potential abuse cases

29. E-Prescribing • Point of care management • Formulary integration • Medication history • Letter of medical necessity • BENEFITS: • Can eliminate prior authorizations at the pharmacy • Patient safety • Lower drug costs

30. PBM: Opioid interventions • Risk identification • Patterns • Long acting opioids • MED threshold • Injured worker education • Prescriber intervention

31. PBM: Prescriber education • Assessment of function • Use of PDMP • Prescription Drug Monitoring Program • Opioid agreement • Urine drug screening • Weaning

32. PBM: Peer interventions • Pharmacist and peer review • Peer interaction • Alternatives • Weaning • Opioid detox • Other interventions: CBT / FRP

33. Case Study: Alerts • Alerts triggered • Excessive duration of use • Concurrent use of opioid and sedative • Action • Opioid program enrollment

34. Case Study: Clinical Interventions • Letter sent to physician • IW education sent • Client enrolled in opioid management program • Physician letter, opioid progress report, pain agreement, drug testing and medication history sent

35. Case Study: Outcomes • Opioid and zolpidem discontinued • Reduced risk of sedation • Reduced risk of OD risk • Savings > $2,500 annually

36. Typical results • 38% reduction in opioid utilization (MED) • 19% reduction in cost • 12-13% of IWs are weaned • 14% referral to an appropriate pain specialist

37. Main cost drivers in WC pharmacy • Cost of the drug • UTILIZATION – especially opioids • PBM strategy • Medical network • Utilization review • Physician education and intervention • Injured worker education

38. What to look for in a PBM • What type of clinical programs do you have to monitor utilization management? • Alerts • Prospective review • Retrospective review • Patient education • Prescriber education • Opioid management programs • Clinician reviews

39. What to look for in a PBM • Are your prior authorization alerts truly real time? • Can we customize who you send them to? • Do you have mobile apps for these? • How do you alert the adjuster about potential abuse? • How do you communicate with prescribers? With injured workers?

40. What to look for in a PBM • What tools do you use in managing opioids and other potentially harmful medications? • How will you educate my staff? • How will you keep me up to date on clinical and regulatory issues that affect my ability to manage opioids and other prescriptions?

41. Questions, Final Comments and Contact Information • Ray Sibley – raymond.sibley@denvergov.org • Marcos Iglesias MD – miglesias@mwecc.com • ask for patient education brochure

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