Strategies aimed at controlling misuse and abuse of opioid prescription medications in a state Medicaid program: a policymaker’s perspective

Abstract

Society in America, like many others, continues to wrestle with the problem of misuse and abuse of prescription opioids. The implications of this struggle are widespread and involve many individuals and institutions including healthcare policymakers. State Medicaid pharmacy programs, in particular, undergo significant scrutiny of their programs to curtail this problem. While recent efforts have been made by government agencies to both quantify and offer methods for curbing this issue, it still falls to each state's policymakers to protect its resources and the population it serves from the consequences of misuse and abuse. This paper details the history of one state Medicaid's management of this issue at the pharmacy benefit level. Examples of various methods employed and the results are outlined and commentary is provided for each method. Regardless of the methods used to address this issue, the problem must still be a priority at all levels, not just for payers.

States With Prescription Drug Monitoring Mandates Saw A Reduction In Opioids Prescribed To Medicaid Enrollees

“…Alternatively, implementation of mandates might have coincided with other reasons for changes in opioid prescriptions, such as Medicaid policies limiting coverage of high-dose opioid prescriptions or placing certain opioids on more restrictive formulary tiers, 30 which would bias our estimates in the opposite direction. Thus, our results are associational rather than causal, but the net impact of the biases (after they cancel each other out) is unknown.…”

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.…”

“…Consequences that affected the target population of the strategy were reported, such as patients not receiving necessary prescriptions 71 ; patients paying for their prescriptions out of their own pockets 71 ; overdose due to rotation from other opioids to methadone 57,74 ; more overdose by morphine, hydromorphone, and heroine 68,75 ; stolen naloxone kits 53,60,82 ; being harassed by police over possession of naloxone 82 ; stigma associated with carrying a naloxone kit 60 ; stigma associated with receiving a prescription for addiction 79 ; a paradoxical increase in overdose because suspension of physicians who were prescribing improperly led to patients on withdrawal and overdosing from other sources 41 ; patients had a false sense of privilege because of participation in an educational session, leading to more opioid abuse 90 ; and possible beliefs that naloxone access enables addiction to opioids. 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 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.…”

“…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.…”