Implementation of an Opioid Management Initiative by a State Medicaid Program

A systematic review of strategies to improve appropriate use of opioids and to reduce opioid use disorder and deaths from prescription opioids

“…Among the 66 strategies described, 19 (29%) had some type of unintended consequence 41,42,[44][45][46]49,53,57,59,60,68,71,[73][74][75]79,82,84,90 and 4 reported no unintended consequence. 47,55,64,65 It was unclear in 43 studies whether there were any unintended consequences or not.…”

“…49 There were consequences to the staff involved in the implementation of strategies: extra burden on the clinical staff (pharmacists and/or physicians) 42,71 ; burden on pharmacy staff who had to assemble intranasal naloxone kits; or risks of needle stick injury to staff who had to assemble intramuscular naloxone. 49 Societal consequences included shifting the opioid crisis to a neighboring region where the strategy had not been implemented 44 ; higher costs 49 ; increase in the proportion of prescriptions of opioids 73,84 ; increase in dose of opioids prescribed 46,59 ; shifting from one opioid to another 59 ; increase in use of benzodiazepines and barbiturates 52 ; and more patients developing opioid tolerance or filling prescriptions from other sources. 45 (For details about the unintended consequences reported in each study, see Appendix 5.…”

“…64 Researchers found that in suspected diversion or doctor shopping, the health care providers using PMPs were 53% less likely to discuss the concerns with the patient and 73% less likely to state to the patient that they were out of stock of the medication. Eight strategies had no effect on appropriate use of opioids, 54,58,59,65,66,74,79,84 seven strategies had a small positive effect, 32,33,42,46,70,77,89 six strategies had a moderate positive effect, 39,43,48,80,85,88 and four strategies had a large positive effect, which included (1) Project Lazarus, a community activation and coalition-building, monitoring, and surveillance data, prevention of overdoses, and use of rescue medication for reversing overdoses and evaluation of the program 41 ; (2) implementation of a treatment agreement developed with cooperation of anesthesiologists, psychologists, nurses, rehabilitation specialists, and clinical pharmacists 45 ; (3) a clinic-wide strategy including opioid prescribing policies and protocols, guidelines to address depression and substance abuse screening, drug selection, dose titration, urine toxicology testing, review of the PMP database and agreement violations, in addition to a monthly meeting with a multidisciplinary committee to review protocols and discuss cases and provider education 67 ; and (4) a multifaceted education initiative regarding pethidine, tramadol, and morphine prescriptions consisting of in-services and feedback by clinical pharmacists, literature discussion, and posters. 91 Impact on misuse, abuse, opioid use disorder (addiction), and diversion Forty studies measured the impact of the strategy on outcomes of misuse, abuse, opioid use disorder, and/ or diversion ( Table 1).…”

“…The results showed that those who attended the educational session were 1.8 times more likely to be discharged due to violation of the treatment agreement, and the explanation was that participants in the educational session could perceive a false sense of privilege becaus they had participated in their care beyond a typical first physician office visit. 90 Sixteen strategies had no effect on this outcome, 31,33,35,37,38,47,52,59,61,66,71,73,75,83,86,89 10 strategies had a small positive effect, 37,38,56,62,65,77,78,85,87,92 six strategies (seven studies) had a moderate positive effect, 34,40,44,58,80,95,97 and seven had a large positive effect, which included (1) a standard protocol for buprenorphine with naloxone for patients with low- The aim of study was to demonstrate noninferiority rather than superiority of the intervention.…”

Health Impact Assessment of the Proposed Opioid Prior Authorization Policy in the State of Utah, USA

“…One study that examined the effects of a PA requirement on the prescribing of Cox-2 inhibitors found that PA caused prescribers to restrict prescriptions to patients who truly needed them, while other patients were switched to less expensive alternatives that did not require PA [17]. Another study of Massachusetts' Medicaid program showed that after implementing PA to reduce high doses and daily doses of prescription opioids and to increase preferred therapeutic alternatives, the number of long-acting opioid analgesic users decreased by 17.8%, and the number of claims decreased by 4.1% [18]. Another study found that PA was associated with an 8% decrease in long-acting oxycodone use [19].…”