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The urgency and unprecedented scale of the opioid crisis demands innovative solutions. Few understand this better than OptumRx Chief Pharmacy Officer David Calabrese. We recently sat down him to get his thoughts on what can be done to address the crisis. A coordinated approach which seamlessly blends clinical, analytic and administrative services is required, he says.

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1.  Given the size of the opioid problem, it seems that prevention is key. What are we doing to prevent opioid abuse before it even starts?

Our prevention efforts are largely focused around improved education. Despite the fact that the opioid crisis is claiming the lives of over 140 US citizens per day, many physicians and most citizens unfortunately still don’t have a full appreciation for the magnitude of the problem. Despite the fact that this crisis is in the news on almost a daily basis, many people don’t realize just how close to home this is for all of us and how readily tied this problem is to our overprescribing, over-demand and overconsumption of prescription opioid drugs.

Accordingly, our educational efforts target all of the key stakeholders here: prescribers; pharmacies/pharmacists and individual citizens.

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As OptumRx Chief Pharmacy Officer, David Calabrese  provides executive level oversight, accountability and input into several of the organization’s most important clinical functions while working closely with other members of the Clinical Leadership team in setting the overall clinical strategy.

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At the patient level, we have developed programming which enables automated mailings to patients who are receiving an opioid for the first time. These materials help to better educate them about what an opioid is, their risks, and how they should and should not be used. In addition, we provide information on the alternative pain management options available to them, how to store opioid medications, and how to dispose of any leftover pills. Disposing of leftover opioids is actually a big deal as studies demonstrate that more than 60% of American families have leftover opioids in their home and these become a primary source of access to those who may be dependent upon or abusing these medications. To that end, we are also partnering with external vendors to deploy educational and operational strategies to promote more widespread disposal of unused opioids.

At the physician and pharmacist level we have developed various tools to help promote more appropriate prescribing and dispensing. These tools have been developed to be in line with the most up-to-date best practice guidelines from the Centers for Disease Control (CDC).

Finally, we are partnering with national advocacy groups like Shatterproof to further drive public awareness of the nature of this crisis and to drive regulatory and legislative changes to further help stem the tide of abuse and rising death tolls.

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2.  We know that people who are just starting out with a course of opioid treatment are especially vulnerable to becoming abusers. How can ORx stop that from happening?

That’s correct. Recently published scientific evidence shows that signs and symptoms of opioid dependency can begin to occur within as little as a few days of continuous opioid therapy. Our efforts here are focused upon limiting, as much as possible, early opioid exposure. We are harnessing the power and the flexibility of our claims adjudication platform, RxCLAIM, to drive clinical edits on these first-fill prescriptions.

Our highly automated system edits allow patients to receive a perfectly adequate supply of opioid medication to fulfill their acute pain management needs. But at the same time, we can restrict both the dose and duration of a ‘first-fill’ opioid prescription in accordance with the quantities and days’ supply limits recommended within CDC guidelines.

These edits were deployed to over 400 OptumRx clients on July 1st of this year and are already having a profound effect. We are driving more appropriate dispensing of these medications, thereby limiting the likelihood for overuse, misuse or leftover opioid drugs sitting in a patient’s home. We have also deployed several other edits at the point-of-dispensing to better protect the safety of patients by limiting dangerous dosing among current users; screening and preventing early refills, duplication of therapy, and preventing potentially dangerous combinations of opioids with other medications that may increase a patient’s risk of overdose. These automated screenings also include edits that will fire when a pharmacy attempts to process an opioid claim for patients who are concurrently receiving a medication for treatment of opioid abuse disorder (e.g., Suboxone), and for women receiving prenatal vitamins (indicative of pregnancy or breast-feeding).

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3.  One of the major issues we face is the sheer number of opioids in circulation. Can you talk about what we can do to reduce the inappropriate supply of opioids?

Today our country consumes approximately 80% of the world’s supply of prescription opioid drugs, yet we represent only 5% of the world’s overall population. More than 240 million opioid prescriptions are issued nationally in this country by our nation’s physicians, which frighteningly represents enough supply to provide every adult US citizen with their own 30-day supply of opioid medication. We desperately need to deploy multidimensional strategies here that can limit the indiscriminate prescribing, dispensing and consumption of these medications. Beyond the first-fill limitations I just described, our Opioid Risk Management initiative also encompasses a wide array of additional components designed to do just that.

For example, using our claims editing capabilities, we are limiting the number of refills of acute opioid prescriptions to decrease unwarranted extended duration of therapy for new opioid users. For existing utilizers, our advanced claims screens ensure appropriate opioid dosing in line with current chronic pain management and CDC guidelines.

For patients who are newly initiating a long-acting opioid product, we require prior authorization in all instances. Prior authorization is a key tool to help ensure a proper diagnosis, to evaluate pain management planning, and to ensure that physicians have an action plan in place to discontinue therapy with time.

From an analytics perspective, we have an unparalleled depth and breadth of resources at our disposal within the Optum enterprise to help drive enhanced surveillance of opioid prescribing, pharmacy dispensing and individual patient consumption. We are routinely deploying much more sophisticated monitoring and comparative assessment targeting patterns of prescribing and dispensing among providers and pharmacies. Better data means we can intervene in a more swift and aggressive manner as needed.

Better data also means that we are better able to identify patients whose utilization patterns place them at the highest risk of overdose and addiction. Along these lines, we are conducting an array of retrospective interventions with both providers and patients to reduce these risks and promote proper abuse management interventions.

Finally, we are currently revisiting our opioid dispensing practices within our own home-delivery facilities. We are examining how to limit the dispensing of large quantities and days supply of opioid therapy, and to ensure proper clinical monitoring, intervention, and counseling support by our home delivery pharmacist team.

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4.  Not everyone who takes an opioid drug gets addicted. How do we sift and sort among all of our members to find out which ones might be headed in the wrong direction?

This is where I see the value of the OneOptum approach most coming into play. OneOptum means leveraging the diverse expertise and resources from our sister organizations like OptumLabs, OptumInsight, Optum Behavioral Health, and Optum Consumer Solutions Group to ensure a more well-rounded, yet targeted approach to those most in need.

For example, on the analytics front we are able deploy more advanced machine learning and predictive modeling capabilities to stratify patients by risk status. Once stratified, we can then deploy more targeted efforts to intervene with patients and providers in a manner best-suited to that risk status, and in ways most likely to drive the most optimal engagement amongst the patients themselves. Our network development and management capabilities within Optum Behavioral Health allow us to support patients where they live by guiding them toward the medication-assisted therapy they need, at the most convenient and qualified locations.

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5.  Even people who have completed an addiction treatment program are at extremely high risk of relapse. What can we do to help prevent continued abuse?

Our job here is to ensure these individuals are receiving the right treatment based upon the current evidence-based best practices. Today, the consensus is clear that this primarily should entail treatment from physicians specifically trained and certified in medication-assisted therapy with medications like buprenorphine, naltrexone and methadone. These drugs have demonstrated the highest level of effectiveness in controlled clinical trials in promoting remission and limiting the risk of relapse, a success rate more than 50% greater than traditional abstinence treatment methodologies.

Unfortunately, for a variety of reasons, a large majority of patients today with dependency and addiction issues are not being treated in this manner. Our efforts are aimed at guiding these high-risk patients toward this more optimal treatment option.

Once a patient is initiated on such therapy, our top priority then becomes ensuring that they remain compliant with their therapy. Here again, we can rely on our claims adjudication capabilities to prevent them from receiving additional opioid prescriptions while they are actively engaged in therapy. We also can deploy additional medication adherence monitoring and utilization management edits in order to ensure that this is the case. For those at highest risk of relapse, we have also developed a ‘pharmacy home’ capability to lock high-risk patients into a single physician, single medication and/or single pharmacy for controlled substances where clinically warranted. This will permit better monitoring for these individuals, prevent doctor and pharmacy shopping, and ensure consistency in their clinical support.

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STATEMENT REGARDING FINANCIAL INFLUENCE:
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.