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Opioids in Workers’ Compensation: PBM Solutions. 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. Ray Sibley - PowerPoint PPT Presentation
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Opioids in Workers’ Compensation: PBM Solutions
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Recording of this session via any media type is strictly prohibited.
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.
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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
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What to Expect
A review of the opioid problem in WCLatest developments - Zohydro ER, Moxduo CRPBM as gatekeeper Opioid strategiesPatient opioid education as part of the strategyWhat to look for in a PBM
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OpioidsOpium (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)
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Daily MED
Morphine equivalence dose (MED)Fentanyl 100X more potent than morphine
10 morphine = 10 hydrocodone
=7 oxycodone= 70 codeine
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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
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Costs: WC
Other med-ical48%
Other drug8%
Opioid4%
Indemnity40%
% Total Cost
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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
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Costs: California
Off work 3.6X longer60% higher litigation ratesClaim costs 2X more expensive
WCRI, 2013
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Adverse effects
ItchingNausea/VomitingDrowsinessEuphoriaConstipationBowel obstructionDepression
AddictionImmune systemEndocrine systemDecreased sex driveHyperalgesiaRespiratory depressionDeath
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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
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Safety: Other drugs
Central nervous system (CNS) depressantsAlcoholBenzodiazepinesSedatives
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Evidence for use
Little-to-noneShort-term studies (1 to 4 months)Most are funded by industryHigh dropout rates Studies exclude patients with mental and substance abuse disorders
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Zohydro ER
Zogenix, Inc.Extended release pure hydrocodone – no APAPNo abuse deterrent properties
Capsules: 10, 15, 20, 30, 40 and 50 mgAWP $7.02 to $8.58
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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
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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
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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%
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Other
Purdue developing an extended release hydrocodone to compete with Zohydro ERMoxduo CR
Combination morphine – oxycodoneRejected last week by an FDA advisory
committee
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Multi-stakeholder solutions
IW MD
PBM PAYER
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PBM: Gatekeeper
Formulary designStep therapyReal-time DUR (prospective)Prior authorization processDrug review (retrospective)Monitoring and identification of riskDataEducation
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Formulary
Right drug for the right patientList of drugs that will be automatically filled• State specific• Acute vs chronic• Injury specific• Claimant specific
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Step therapy
Requires the use of a certain drug before escalating to another, more expensive or dangerous drug
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Drug utilization review (DUR)
Correct dosesEarly refillsDuplicate fillsQuantitiesDangerous
combinations
Multiple or unauthorized prescribers or pharmacies
Formulary Step therapy
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Prior authorization
Rx at pharmacyTriggerRejectionP/A alert to payerDecisionAction
• Time-sensitive• Requires knowledge on part of the
adjuster
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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)?
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Knowledge and decision support
Adjusters are not pharmacists or cliniciansEducational and informational support
Internal (NCM, MD, UR) and external
Does the PBM help the payer make a good decision?
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Prior authorization
BENEFITS:• Multiple user roles streamline the process
• Team collaboration• Increased efficiency for nurses who data sift for potential abuse cases
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E-Prescribing
Point of care managementFormulary integrationMedication historyLetter of medical necessity
BENEFITS:• Can eliminate prior authorizations at the pharmacy
• Patient safety• Lower drug costs
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PBM: Opioid interventions
Risk identificationPatternsLong acting opioidsMED threshold
Injured worker educationPrescriber intervention
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PBM: Prescriber education
Assessment of functionUse of PDMP
Prescription Drug Monitoring ProgramOpioid agreementUrine drug screeningWeaning
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PBM: Peer interventions
Pharmacist and peer review Peer interactionAlternativesWeaningOpioid detox Other interventions: CBT / FRP
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Case Study: Alerts
Alerts triggered• Excessive duration of use• Concurrent use of opioid
and sedative
Action• Opioid program
enrollment
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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
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Case Study: Outcomes
• Opioid and zolpidem discontinued
• Reduced risk of sedation• Reduced risk of OD risk
• Savings > $2,500 annually
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Typical results
38% reduction in opioid utilization (MED)19% reduction in cost12-13% of IWs are weaned14% referral to an appropriate pain
specialist
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Main cost drivers in WC pharmacy
1.Cost of the drug 2.UTILIZATION – especially opioids• PBM strategy• Medical network• Utilization review• Physician education and intervention• Injured worker education
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What to look for in a PBM
1.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
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What to look for in a PBM
2. Are your prior authorization alerts truly real time?
3. Can we customize who you send them to? 4. Do you have mobile apps for these?5. How do you alert the adjuster about
potential abuse?6. How do you communicate with prescribers?
With injured workers?
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What to look for in a PBM
7. What tools do you use in managing opioids and other potentially harmful medications?
8. How will you educate my staff?9. How will you keep me up to date on clinical
and regulatory issues that affect my ability to manage opioids and other prescriptions?
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Questions, Final Comments and Contact Information
Ray Sibley – [email protected]
Marcos Iglesias MD – [email protected] for patient education brochure
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