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The United States is experiencing an epidemic of opioid abuse. It is estimated that 4.5 million Americans have a substance use disorder involving opioid prescription painkillers.1 Tragically, there is a death every 13 minutes from opioid overdose.2


Ordinary pharmacy benefit manager (PBM) programs that focus on drugs of abuse are not sufficient to combat a problem with so many complicating variables. Multiple social and human needs are at stake that will require careful balancing.

At OptumRx, we recognize that attacking such a complex, deeply embedded problem will require a comprehensive approach in order to both stem the tide while also meeting the legitimate need for sensible pain management. We call this approach OptumRx Opioid Risk Management.

No shortage of pain

Earlier, we have described how overprescribing is the main force fueling the opioid abuse epidemic. In 2013, nearly 250 million prescriptions for opioid pain medication were written by health care providers. That’s enough for every American adult to have a bottle of pills.3

And yet, while it is true that opioids are overprescribed, it is also true that millions of Americans live with acute or chronic pain. Many of them rely on prescription drugs, including prescription opioids to improve their ability to function and maintain their quality of life.4

An Institutes of Medicine (IOM) report found that at least 116 million U.S. adults suffer from common chronic pain conditions, a number IOM feels is well understated. That’s more than the number affected by heart disease, diabetes, and cancer – combined.4

Furthermore, everyone is at some risk of acute or chronic pain, whether from an illness, an injury, or some other factors. Across all ages, acute and chronic pain is one of the most common reasons for physician visits.4

Severe chronic pain imposes a significant financial burden on the affected individuals, as well as on their families, their employers, and the nation as a whole. The annual economic cost of chronic pain in adults, including health care expenses and lost productivity, is $560–630 billion annually.4

But the fact that there are millions of people with a legitimate need for pain relief is only the beginning of the problem we need to solve. The second part of the problem is that prescription opioid use is, by now, deeply entrenched in the clinical treatment culture in the U.S.

New CDC Guidelines

In 2016 the Centers for Disease Control and Prevention (CDC) published the CDC Guideline for Prescribing Opioids for Chronic Pain. These new guidelines provide recommendations to primary care clinicians about how to prescribe opioids appropriately to improve both pain management and patient safety.5

The CDC intends that these guidelines will help clinicians determine if and when to start prescription opioids for chronic pain, give guidance about medication selection, dose, and duration. In addition, it provides guidance on when and how to reassess patient progress and discontinue opioid medication if needed. Overall, CDC sees the need for doctors and patients to assess the benefits and risks of prescription opioid use – together.5

While the new CDC prescribing guidelines are welcome, they are only a first step toward a solution. At this point, the tendency to aggressively treat pain using opioids is firmly entrenched in the medical community. For example, just last year the National Safety Council conducted a national survey of physicians who spend over 70% of their time seeing patients for pain. What they found was revealing:

  • 99% of doctors prescribe highly addictive opioids for longer than is recommended by the CDC (three days).6
  • 74% of doctors incorrectly believe morphine and oxycodone – both opioids – are the most effective way to treat pain.6
  • 67% of doctors are, in part, basing their prescribing decisions on patient expectations.6

That last bullet point is significant because it highlights a troublesome feedback loop at work. When doctors say that they are making prescribing decisions based on patient expectations, what they mean is that patients have learned to associate quality of care with the liberal use of pain killing medications.7

Correcting this damaging misperception will require extensive education, as well as targeted efforts to control excessive opioid use.


Driving solutions

Pain management experts point out that the way we prescribe opioids must strike a balance between the urgent need to avoid the abuse of prescription opioids with the need to ensure legitimate access to patients in pain.8

We also need to account for the fact that pain is a highly complex dynamic, which is unique to each individual. Each person’s pain experience can be influenced by a unique array of variables, including psychological and sociocultural factors, not to mention that of course pain also varies by procedure.8

These variables – and others – describe a clinical challenge that is central to opioid prescribing: How do we adequately treat pain without contributing to the problem?8

The problem of pain is another illustration of why there are no simple solutions to the opioid abuse problem. At OptumRx, we recognize that attacking such a complex, deeply embedded problem will require a comprehensive approach.

Public health experts agree that only a multi-pronged approach is sufficient to address the prescription opioid epidemic.9 Therefore, we are preparing to deploy five interrelated strategies we call OptumRx Opioid Risk Management.

Opioid Risk Management strategies

When we analyzed the opioid abuse problem from a systems perspective, it became clear that one of the biggest contributions we could make as a PBM would be to actually reduce the inappropriate supply (dispensing, prescribing or use) of opioid drugs. We can use our sophisticated clinical rules engine to screen for inappropriate opioid supplies at the point of sale – and stop it.


Rule-driven interventions

This requires the use of both concurrent (real-time) data, together with point-of-service claims-management tools to identify unsafe prescribing, unsafe dispensing, and unsafe member utilization. This pinpoint data allows us to intervene exactly where we need to, whether that means with the patient, with the pharmacist or with the doctor. Or all three.

This image illustrates the power of applied data to target the right population:

Chart illustrates the power of applied data to target the right population


Many PBMs (and insurers with pharmacy services) offer basic controlled substances utilization management programs such as prior authorization, precertification and maximum quantity limits per prescription. They may also perform prescription claims reviews to identify individuals, pharmacies and prescribers that may be fraudulently using or dispensing controlled substances.9

The problem with the basic PBM approach is that it is not enough to simply reduce the number of prescriptions filled, although that is important. Nor is it sufficient to look backward in time to identify troubling patterns of behavior, although that is also important.

We have greatly expanded our concurrent utilization drug review (CDUR) edits and plan design edits at the point of service. So when a prescription is issued for an opioid and that is inappropriate for any reason – too many pills, dose too strong, a patient who is already on benzodiazepines, a patient on prenatal vitamins, a patient actively in medication-assisted treatment for OUD, and many more, we have an edit in place.

The system dictates that the prescriber and the dispensing pharmacist understand the safety risks and take the time to assess risks versus benefits before moving forward with opioid treatment for their patient. At the pharmacist-level, additional steps must be taken to talk to the patient and to the physician, and make sure they're aware of the potential safety issue and assess treatment alternatives where possible.

OptumRx leverages powerful analytic capabilities to take additional steps after the first fill of an opioid as well. For example, we need to determine why or even if that patient needs to stay on that drug, because too many patients do continue unnecessarily after their first fill.

The new CDC guidelines promote evidence-based safety standard limits on the amount of opioid drug a patient should consume on a daily basis. These are based upon what are called “morphine-milligram” dosing equivalents (MMEs).10 This is a numerical standard which allows us to compare the relative potency of different opioid drugs, which in turn makes it easier to evaluate how much risk each patient faces.10

Just to illustrate the impact of the MME standard, we know that the risk of chronic opioid use increases with each additional day of medication supplied, starting with the third day. The sharpest increases in chronic opioid use are noticed with an initial 10 or 30 day supply.11 And yet, in a study reported to the 2017 scientific meeting of the American Pain Society, one in four patients had at least 200 unused morphine equivalents left over at 1 month post-surgery.8

These leftover units of opioid drugs can be extremely dangerous. This graph shows that patients who receive high-dose opioid prescriptions face a risk of overdose that is nine times higher than low-dose patients:

Chart  illustrates opioid deadly use

Additional edits screen for patients who are pregnant in order to combat an awful condition called neonatal abstinence syndrome (NAS). NAS babies are born to mothers who have used opioids during pregnancy and they can actually experience difficult opioid withdrawal symptoms.

The number of delivering mothers using or dependent on opiates rose nearly five-fold from 2000 to 2009, to an estimated 23,009. There was a five-fold increase in the proportion of babies born with NAS from 2000 to 2012, when an estimated 21,732 infants were born with NAS—equivalent to one baby suffering from opiate withdrawal born every 25 minutes.12

Newborns with NAS were more likely than other babies to also have low birth weight and respiratory complications. In 2012, newborns with NAS stayed in the hospital over seven times longer compared to other newborns, costing hospitals an estimated $1.5 billion.12

Network audits

In addition to ongoing monitoring of members, pharmacies and providers, OptumRx uses sophisticated forensic techniques to identify questionable billing practices by pharmacies. Our multi-faceted network audit department leverages broad analytics and procedures such as standard desktop audits to identify claims for further investigation. Pharmacies confirmed as illegally supplying opioids are referred to the plan or law enforcement agencies as appropriate.


In a previous article, we discussed the first two strategies: Prevention & Education, and Minimizing Early Exposure.

OptumRx Opioid Risk Management uses advanced analytics to confront opioid misuse before it occurs, while supporting chronic individuals and their recovery. Our end-to-end solution drives increased opioid safety and prevention through engagement, smart prescribing, and ongoing monitoring. Ultimately, its goal is for improved health outcomes and reduced overall health care costs and our mission to get out in front of misuse, abuse, dependence and diversion before it starts, as well as support at risk, high risk and chronic populations in need.

Please contact your representative to learn more about how OptumRx is uniquely positioned to provide the critical leverage to execute the massive structural and behavioral shifts required to end the opioid epidemic.

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  1. Understanding the Epidemic: Drug Overdose Deaths in the United States Continue to Increase in 2015. Centers for Disease Control and Prevention. Accessed Aug. 25, 2017

  2. Centers for Disease Control and Prevention; National Center for Health Statistics;  2017. Accessed at

  3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Fact Sheet: CDC Guideline for Prescribing Opioids for Chronic Pain. [PDF]

  4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. Accessed at: on 05.24.2017.

  5. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain. Page last updated: March 15, 2017. Accessed at: on 05.24.2017.

  6. National Safety Council. Prescriber attitudes and behavior related to prescription opioid pain medication. March 13, 2016. Accessed at: on 05.16.2016.

  7. Hospitals & Health Networks. Doctors Urge CMS, Joint Commission to Rethink Pain Treatment to Help Stem Opioid Epidemic. April 15, 2016. Accessed at: on 09.06.2016.

  8. Medscape Coverage from the American Pain Society (APS) 2017 Annual Scientific Meeting: Opioid Oversupply Common After Surgery. May 22, 2017. Accessed at: on 05.23.2017.

  9. Johns Hopkins Bloomberg School of Public Health. The Prescription Opioid Epidemic: An Evidence-Based Approach. Nov. 2015. Accessed at: on 05.02.2016.

  10. National Safety Council. Prescription Nation 2016: Addressing America’s Drug Epidemic [PDF]

  11. HealthDay News. Opioid Dependence Can Start in Just a Few Days. March 16, 2017. Accessed at: on 06.02.2017.

  12. National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome. Last updated September 2015. Accessed at:

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This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article.