The role of health plans in addressing the opioid crisis: A qualitative study

Davis, Margot Trotter; Bohler, Robert; Hodgkin, Dominic; Hamilton, Greer; Horgan, Constance M.

doi:10.1016/j.josat.2023.209022

Cited by 3 publications

(4 citation statements)

References 32 publications

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“…These complex opioid prescribing policies can complicate clinical decisions when caring for patients requiring long-term high dose opioid analgesic therapy and thus in uence providers' treatment decisions (7). Unfortunately, this in uence can result in patients with chronic pain receiving fewer opioids prescribed and initiation of tapering and discontinuation (7,9,10,22,23). Balancing the requirements of these policies with providing individualized analgesia for individuals with chronic non-malignant pain, which the guideline recognizes as important, remains challenging (19).…”

Section: Discussionmentioning

confidence: 99%

“…The CDC no longer recommended speci c opioid dose limitations or treatment duration and strongly warned against abrupt tapering. The intention for the recommendations on speci c doses and durations of treatment was exibility to inform shared patient and clinician decision making and assist in meeting individual patients' needs (9,19). The impact of the 2022 revision as evidenced by increased exibility by payer policy is unknown.…”

Section: Introductionmentioning

confidence: 99%

“…Commercial and public (Medicaid) payers use opioid prescribing policies as a strategy to achieve safer opioid prescribing (9,20). However, the implementation of these prescribing policies also complicate the opioid prescription process, potentially decreasing access to required opioid medications at the point of prescribing and at the pharmacy representing a barrier to care.…”

Section: Introductionmentioning

confidence: 99%

“…However, the implementation of these prescribing policies also complicate the opioid prescription process, potentially decreasing access to required opioid medications at the point of prescribing and at the pharmacy representing a barrier to care. 3,9.21,22,23 The numerous payer policies are time-consuming to accommodate within the clinic and pharmacy work ow, particularly when dealing with multiple health care plans (9,20).…”

Section: Introductionmentioning

confidence: 99%

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The revised CDC Chronic pain guidelines and payer opioid analgesic policies in Michigan

Lehr,

Arfken

2023

Preprint

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Background: Publication of the 2016 United States Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain informed restrictive opioid prescribing policies by state specific commercial and public payers. These policies restricted access to opioid analgesics for patients with intractable pain conditions (e.g. sickle cell disease) who had been receiving long-term opioids at dosages exceeding 90 MME/day. The revised 2022 guidelines no longer recommends specific opioid dose limits or duration of therapy for chronic pain, emphasizing individualized therapy. The impact of the revision on payer opioid prescribing policies is unknown. We examined number and type of policies allowing flexibility in opioid daily dosage (morphine milligram equivalent, MME) and duration of therapy following the 2022 CDC revision. Methods: Policies for seven large commercial payers in Michigan and for Medicaid fee-for-service from 2019–2022 were reviewed and categorized. Policies for prior authorization, quantity limits, duration, and opioids > 90 MME/day for chronic pain were documented by year for each individual payer. Results: The eight payers implemented 207 new actions (mean = 10.3 per year) with the least number during 2020 (n = 25) and the most in 2021 (n = 51). The most common action was limitations on number of days for initial prescriptions (n = 40). All payers had opioid limits 50–120 MME/day. For 6/8 payers, the limit was 90 MME/day unchanged from 2016 CDC guidelines. Prior authorization and/or pharmacist-edit policies were required to exceed opioid limits. In 2022, 7/8 payers exempted sickle cell pain from limits versus 5/8 in 2019. Number of days supply for initial prescription depended on formulation, for long-acting opioids 4/8 payers allowed 30-days and 2/8 allowed 90 days. Discussion: The eight commercial and public payers continued to implement complex opioid prescribing policies. Increased flexibility in daily opioid limits and duration of therapy was available only through prior authorization, pharmacist edits or exemption for the diagnosis of sickle cell pain. Conclusion: Payer policy implementation in one state did not reflect the 2022 CDC revised guidelines for individualized opioid prescribing for chronic pain. The impact of slow payer uptake of the 2022 guidelines on patient care is unknown, requiring continuous monitoring.

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