State Efforts to Confront

the Opioid Epidemic

April 13, 2016
Allan Coukell, BSc Pharm
Senior Director, Health Programs
The Pew Charitable Trusts

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Substance use disorders
5

Pew Efforts on Substance Use Disorders

1)

Reduce the inappropriate use of prescription drugs while ensuring

that patients with legitimate medical needs have access to effective
pain control, and

2)

Advance federal and state reforms that improve the effectiveness of

treatment for alcohol and opioid use disorders through increased use
of medication-assisted treatment.

State Efforts to Confront Opioid Epidemic

Todays discussion will cover six themes:

1) States roles in substance abuse prevention and treatment

2) Growing momentum for state action
3) Medication-assisted treatment
4) Parity
5) Harm reduction
6) Efforts to deter and identify misuse and abuse

Opioid Epidemic: Burden of Disease

State Roles in Combating the Epidemic:

Funding

State Roles in Combating the Epidemic:

Substance Use Disorder Agencies

State Roles in Combating the Epidemic:

Medicaid and the ACA

Prior to the ACA, most state Medicaid programs did not

cover childless adults and covered only a limited number

of parents

Coverage of substance abuse services has traditionally

been an optional Medicaid benefit and many states have

provided only limited substance abuse service coverage.

Nearly 12 percent of Medicaid beneficiaries over 18 have

a SUD

State Roles in Combating the Epidemic:

Medicaid and the ACA

Growing Interest in Tackling the

Epidemic at the State Level

2016 state of the state addresses covering substance

abuse: Arizona, Florida, Indiana, Massachusetts,
Missouri, New Jersey, Oklahoma, Vermont, and West
Virginia

National Governors Association has been assisting

states in developing tailored responses to the epidemic;

this year they made recommendations for federal action
to support states

State Task Forces to Address Opioid

Overdose

Indiana
Maryland
Michigan
New York
Pennsylvania
Rhode Island
Virginia

Massachusetts Opioids Legislation

Medication-Assisted Treatment

Medication-Assisted Treatment
Approach that uses FDA-approved drugs, often in combination with
psychosocial treatments, for patients with opioid use disorders.
The FDA has approved three medications in several different
formulations for the treatment of opioid use disorder:
Methadone
Buprenorphine
Naltrexone (oral or injectable)

Highly effective

Medication-Assisted Treatment
Highly effective:
Illicit opioid use is reduced by 40-70 percent on
average
Risk of HIV infection is reduced six fold and risk of
infection with hepatitis C and B drops
Methadone decreases opioid overdose by 40-80
percent
Employment increases
Reduced criminal activity

Medication-Assisted Treatment

Medication-Assisted Treatment

Via Nora Volkow, National Institutes on Drug Abuse

Medication-Assisted Treatment
< 20% of people with an opioid use disorder receive treatment in
any given year

Demand Exceeds Capacity for

Medication-Assisted Treatment
Demand far exceeds capacity

Jones, CM, et al. National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted
Treatment.American Journal of Public Health: August 2015, Vol. 105, No. 8, pp. e55-e63.

Demand Exceeds Capacity for

Medication-Assisted Treatment

Jones, CM, et al. National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted
Treatment.American Journal of Public Health: August 2015, Vol. 105, No. 8, pp. e55-e63.

States Opportunities to Increase

Access to MAT
Include all medications on Medicaid preferred drug
lists without restrictions not based on evidence,
such as lifetime limits
Provide sufficient coverage and reimbursement for
services that support MAT
Ensure that treatment providers offer MAT, through
regulation of treatment providers (MO)
Improve linkages between providers (VT)
Fund staff to support MAT in community health
centers (MA)

Case Study: Vermont Hub and Spoke

Goal is to enhance the provision of MAT for
individuals with opioid addiction
Hub: Regional specialty addictions treatment
centers regulated as opioid treatment programs and
operated by community behavioral health agencies
Spoke: Teams of health care professionals led by
physicians who prescribe buprenorphine in
practices

Case Study: Vermont Hub and Spoke

Source: NASADAD 2015 Annual Meeting, VT Medicaid claims

Criminal justice
Diversion
Drug courts
MAT
Return to the community

Legal Action Center : http://lac.org/what-we-do/substance-use/parity/ and http://lac.org/resources/substance-useresources/parity-health-care-access-resources/

Parity: A New Frontier

The 2008 federal Mental Health Parity and Addiction
Equity Act (MHPAEA) prohibits discrimination in health
insurance coverage of substance use disorder and
mental health benefits
Plans subject to the federal parity law are precluded
from providing these benefits in a more restrictive way
than other covered medical benefits
States are primarily responsible for monitoring and
enforcing the federal parity law for group and individual
market coverage

Legal Action Center : http://lac.org/what-we-do/substance-use/parity/ and http://lac.org/resources/substance-useresources/parity-health-care-access-resources/

Parity Enforcement

Harm Reduction: Naloxone

Opioid antidote, also

known as Narcan

More than 150,000

people received
naloxone kits from
community outreach
programs,1996 and
2014

More than 26,000

overdoses were
reversed using those
kits, according to the
CDC

Source: Network for Public Health Law

Harm reduction: Needle Exchange

Indiana reversed ban in response to spike in HIV cases tied to

opioid abuse

Kentucky also passed legislation allowing local health departments

to run programs

Photo: Seth Herald for NPR

Harm Reduction: Safe Injection Sites

No safe havens for injecting illegal drugs exist in the US, but
it is being considered in some states, such as CA and MD

Photo: The Associated Press

State Efforts to Deter and Identify

Misuse and Abuse

Patient Review and Restriction Programs

Prescription Drug Monitoring Programs
Methadone for Pain Control

What is a Patient Review and

Restriction Program (PRR)?

Programs that Medicaid and private insurance plans use to identify

and manage patients at-risk for prescription drug abuse

Plan identifies a patient receiving large quantities or duplicative

opioids from multiple prescribers or pharmacies

Patient is required to use a designated pharmacy and/or prescriber to

obtain controlled substance prescriptions

PRR programs can improve continuity of care

Patient protections ensure access to pain medicine while lowering the
risk of overdose

Defining Risk for Opioid Overdose

Yang Z, et al J Pain. 2015;16(5):445-53.

How do PRRs currently operate?

PRRs are Widely Used in Medicaid

Programs

States Structure their Medicaid

PRRs in One of Three Ways

www.pewtrusts.org/PRRreport

More than Half of Medicaid PRRs Do Not

Offer Beneficiaries Additional Services

www.pewtrusts.org/PRRreport

Most Medicaid PRRs Do Not Have Access to the

State Prescription Drug Monitoring Programs

www.pewtrusts.org/PRRreport

Medicaid PRR Program Outcomes

TN: decreases in controlled substance use when comparing prior to and at
least six months after PRR enrollment
51 percent decrease in pharmacies visited
33 percent decrease in prescribers visited, and
46 percent decrease in number of paid prescriptions

MN: estimated cost savings of $1.2 million in the first year of patient enrollment
Reductions in prescriptions, emergency room utilization, and clinic visits
Average savings of $4,800 per patient

OK: decreases in pre- and post- enrollment in the mean monthly average for:
Narcotic prescriptions (from 2.16 to 1.32),
Emergency department visits (from 1.26 to 0.81),
Number of pharmacies visited (from 2.05 to 0.89), and
Number of prescribers seen (from 2.48 to 1.63)

Prescription Drug Monitoring

Programs (PDMPs)

Prescription Drug Monitoring Program Training and Technical Assistance Center, PDMP Legislation & Operational Dates,
http://www.pdmpassist.org/content/pdmp-legislation-operational-dates

Prescription Drug Monitoring

Programs (PDMPs)

State-based electronic databases that collect information

about dispensed controlled substances

Most programs have become active in the last decade

Emphasis has shifted to strategies to optimize, or enhance, these
programs

On the federal level, use of PDMPs has been encouraged

as part of broader plans to address opioid-related
overdoses and deaths

The structure and use of these databases varies among

states

Prescription Drug Monitoring Program Training and Technical Assistance Center, PDMP Legislation & Operational Dates,
http://www.pdmpassist.org/content/pdmp-legislation-operational-dates

PDMPs are unlikely to

reach their full potential in
reducing prescription
drug misuse and abuse
and diversion if they are
not utilized.
Office of National Drug
Control Policy, 2015

https://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/2015_national_drug_control_strategy_0.pdf

Optimizing Prescriber Utilization of

Prescription Drug Monitoring Programs

Unsolicited Reporting
Prescriber Use Mandates
Delegation
Data Timeliness
Streamlined Enrollment
Educational and Promotional Initiatives
Health Information Technology Integration
Enhanced User Interfaces

Unsolicited Reports

Proactive communications that alert users about potentially

harmful drug use or prescribing activity based on the data
contained in the PDMP

Based on thresholds associated with increased risk of harm or

abuse

Notifications may be sent to:

Prescribers
Dispensers
Regulatory agencies
Law enforcement

Available at http://www.pdmpassist.org/pdf/Prescribers_Sol_Unsol_Reports.pdf

Massachusetts Assessment of
Unsolicited Reporting

MA adopted electronic alerts in December 2013

Initial results:
21 percent of prescribers who received an alert logged
into the PDMP for the first time
59 percent of patients who were the subject of an alert
sent the first month did not meet the threshold again for
the next six months
Prescriber survey (n = 87)
Only 24 percent were aware of all other prescribers providing
controlled substances to their patients
85 percent said viewing PDMP data increased
confidence in
prescribing decisions
http://www.pdmpexcellence.org/sites/all/pdfs/MA%20PMP%20electronic%20alert%20NFF.pdf

Mandatory PDMP Use

Available at http://www.namsdl.org/IssuesandEvents/
2015%20Annual%20Review%20of%20Prescription%20Monitoring%20Programs%20graphics.pdf

University of Kentucky Evaluation of

Mandate Through One Year

Pharmacist registrations increased 322% & queries increased

by 124%.

Mean annual queries per prescriber increased 550 percent,

from 34 queries in 2009 to 221 in 2013.

Both opioid and benzodiazepine prescribing decreased; Highdose oxycodone Rx decreased.

Doctor Shopping decreased by over 50%.

UK study available at: http://www.chfs.ky.gov/os/oig/KASPER.htm

Reports Requested Kentucky PDMP:

2005 through 2015

UK study available at: http://www.chfs.ky.gov/os/oig/KASPER.htm

New York State

Requests for reports increased from an average of 11,000 per
month to 1.2 million per month within 6 months.

Opioid Rx decreased by 8.72%, and individuals receiving an

opioid Rx decreased by 10.4%.

Yet, Rx for opioids commonly used in chronic cancer pain

treatment (e.g. morphine and fentanyl) were not adversely

affected.

Buprenorphine prescriptions, used in treating opioid addiction,

increased (14.6%) and the # of patients with this drug increased
(12.8%) in the fourth quarter of 2013 as compared to the same
quarter in 2012.

NY State: Multiple Provider Episodes

and PDMP Report Requests

October 2011 - December 2015

Number of Patients Meeting Multiple Provider Episodes Threshold

Number of PDMP Report Requests

Patients Me eting Multiple

Pro vide r Episode
Threshold
P DMP Re port Reque sts

Note: Multiple provider episodes defined as patients using five or more prescribers
and five or more dispensers within the month. Source: New York PDMP

Provision for Prescriber Delegates

Delegates can obtain PDMP reports for prescribers, when

state law permits.

Prescribers set up subaccounts

Prescribers can audit delegates use.
Prescribers are accountable for delegates use.

All states with comprehensive prescriber use mandates

permit delegates.

As of 2015, 40 states permit delegates.

Major PDMP Funding Mechanisms

Grants
Federal (Bureau of Justice Assistance, Centers for Disease Control
and Prevention)
Private (National Association of State Controlled Substances
Authorities)

State general revenue funds

Regulatory board funds
Licensing fees
Controlled substance registration fees

Available at http://www.pdmpassist.org/pdf/PDMP_Funding_Options_TAG.pdf

Methadone

Methadone
A synthetic opioid that has been used since the 1960s to treat
heroin addiction by mitigating withdrawal symptoms1
In the mid-1990s, methadone began to be increasingly prescribed
for the treatment of chronic noncancer pain1
Accounts for just two percent of opioid pain reliever prescriptions,
yet is implicated in nearly one third of these deaths2

Centers for Disease Control and Prevention, Vital Signs: Risk for Overdose from Methadone Used for Pain Relief United States, 19992010, Morbidity and Mortality
Weekly Report 61, no. 26 (2012): 493-497, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm
2 Centers for Disease Control and Prevention, Vital Signs: Prescription Painkiller Overdoses: Use and Abuse of Methadone as a Painkiller,
http://www.cdc.gov/vitalsigns/pdf/2012-07-vitalsigns.pdf
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Why Is Methadone Still Prescribed for Pain?

Factors that may be driving use include:1,2,3

Long duration of action
Effective treatment for refractive pain
Cost differential

Methadone is a preferred pain reliever for most state Medicaid

programs.4

30 states currently list methadone as a preferred analgesic for pain 5

Food and Drug Administration, Methadone Hydrochloride Approved Label 4/14/2014,

http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/090707Orig1s003lbl.pdf
2.
The American Academy of Pain Medicine, The Evidence Against Methadone as a Preferred Analgesic: A Position Statement From the American Academy of
Pain Medicine, http://www.painmed.org/files/the-evidence-against-methadone-as-a-preferred-analgesic.pdf
3.
CDC,Overdose Deaths Involving Prescription Opioids Among Medicaid EnrolleesWashington, 2004-2007, MMWR, 58, no 42 (2009):1171-5
4
CDC, Vital Signs: Prescription Painkiller Overdoses: Use and Abuse of Methadone as a Painkiller, http://www.cdc.gov/vitalsigns/pdf/2012-07-vitalsigns.pdf
5.
The Pew Charitable Trusts, in-house research on state Medicaid fee-for-service preferred drug lists
.1

Risks of Methadone Used for Pain

The Pew Charitable Trusts, Prescription Drug Abuse Epidemic: Methadone, (2014), http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2014/08/prescription-drugabuse-epidemic

Methadone Use by State

Centers for Disease Control and Prevention, Vital Signs: Prescription Painkiller Overdoses: Use and Abuse of Methadone as a Painkiller,
http://www.cdc.gov/vitalsigns/pdf/2012-07-vitalsigns.pdf

Strategies Used by State Medicaid

Programs to Address Methadone Safety

Remove methadone from the preferred drug list (PDL)

In 2013, North Carolina became the first state to remove
methadone from its PDL1
D.C.2 and 10 other states followed

Give methadone non-preferred status on drug lists

Examples: Alaska,3 Minnesota,4 Nevada,5 Tennessee,6 West
Virginia7
Vestal C, Most States List Deadly Methadone as a Preferred Drug, Stateline, Apr. 23, 2015, http://www.pewtrusts.org/en/research-andanalysis/blogs/stateline/2015/4/23/most-states-list-deadly-methadone-as-a-preferred-drug
2
District of Columbia. Medicaid Preferred Drug List, Available at https://dc.fhsc.com/downloads/providers/DCRx_PDL_listing.pdf
3
Alaska Medicaid Preferred Drug List, Available at http://dhss.alaska.gov/dhcs/Documents/pdl/PDF/2015-PDL-DRAFT.pdf
4
Minnesota Medicaid Preferred Drug List, Available at http://www.dhs.state.mn.us/main/idcplg?
IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&Rendition=Primary&allowInterrupt=1&noSaveAs=1&dDocName=dhs_id_016922
5
Nevada Medicaid Preferred Drug List, Available at https://www.medicaid.nv.gov/Downloads/provider/NV_PDL_20150101.pdf
6
Tennessee Medicaid Preferred Drug List, Available at https://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Drug_Criteria/TennCare_PDL.pdf
7
West Virginia Medicaid Preferred Drug List, Available at http://www.dhhr.wv.gov/bms3/Pharmacy/Documents/WV%20PDL01282015%20v2015%202e.pdf
1

Strategies Used by State Medicaid

Programs to Address Methadone Safety

Implement prior authorizations

Examples: Massachusetts1 & Delaware2

Introduce stepped therapy

Examples: Ohio3

Provide education to improve use

Example: Washington State conducted outreachwarning letters
and office visits to educate top prescribers about pharmacology.4

Massachusetts Medicaid Preferred Drug List, Available at https://masshealthdruglist.ehs.state.ma.us/MHDL/pubdownloadpdfcurrent.do?id=45

Delaware Medicaid Preferred Drug List, Available at http://www.dmap.state.de.us/information/Pharmacy/DEM%20PDL.pdf
3
Ohio Medicaid Preferred Drug List, Available at:
http://medicaid.ohio.gov/Portals/0/Providers/ProviderTypes/MedicaidDrugProgram/PharmacyandTherapeuticsCommittee/2014-07-29-PDLrevised.pdf
4
Vestal C, Most States List Deadly Methadone as a Preferred Drug, Stateline, Apr. 23, 2015, http://www.pewtrusts.org/en/research-andanalysis/blogs/stateline/2015/4/23/most-states-list-deadly-methadone-as-a-preferred-drug
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