Tuesday, April 28, 2015

A Terrible Excuse for a Formulary

I'm sitting in New Orleans, Louisiana at the annual RIMS conference and right down the road in Baton Rouge, the state is about to do something that will put a lot of injured workers at risk.  Ironic, right?

Louisiana Senate Bill 256 is scheduled for a hearing at 10 am central tomorrow.  I hope someone at that hearing points out the following:

1) Evidence based medicine isn't produced by a panel.  The bill calls for a panel (made up of one doctor and four pharmacists) to meet regularly and, by majority vote, decide what changes should be made to the formulary.  This is an awful idea.  Evidence based medicine is developed through peer reviewed research and should be adopted as the evidence dictates, not according to a majority vote.  For a brief glimpse into how guidelines adoption by committee works (or, rather, doesn't work) in Lousiana, check this out.

2) But should the state insist on a committee, we need to move beyond a single doc and four pharmacists.  Where is the voice of the employer on this proposed panel?  Where is the voice of the injured worker?  Wh y does a single doc and four pharmacists get to decide?

3) Worst of all... and the point that will lead to the greatest risk to injured workers... and the part of the bill that shows how very little its authors know about medical management: All "non-narcotic drugs" will be approved and not require pre-authorization.  Since when are narcotics the only dangerous drugs in work comp?  Hydrocodone might require authorization under this bill, but injured workers can have all the benzodiazepines, antidepressants, antipsychotics, anticonvulsants, sleep aids,  muscle relaxants, etc that they'd like.  The distinction between drugs that require authorization vs those that do not shouldn't be based on the drug's class.  Rather, good formularies assess the appropriateness of a given medication for first line therapy, regardless of class.  The approach outlined in SB 256 is worse than silly; it's dangerous.

A closed formulary is a great idea in concept and I genuinely hope to see Louisiana adopt one.
Just not this one.

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Tuesday, April 21, 2015

The Worst Kind of "Whack-a-Mole"

I've heard the "whack-a-mole" analogy applied to nearly every facet of business.  Frankly, it's a tired and worn out analogy.  But it's also an image that paints a clear picture of a common issue and, thus, we can't seem to escape its constant use.  We're always solving one problem only to create a myriad of unanticipated and unintentional consequences that require ever greater effort to address.  Hit one "mole" on the head and another quickly pops up elsewhere to take its place.

Yesterday, the Journal of the American Medical Association released a study that highlights the worst kind of "whack-a-mole" imaginable.

The good news: After the introduction of an abuse deterrent formulation of Oxycontin and the discontinuation of propoxyphene in the latter half of 2010, overall opioid prescriptions appear to have declined 19% vs. where we would have expected them to be.  Mind you, that's not a 19% reduction in scripts; rather, it's a 19% reduction vs. a statistical forecast of a line that was trending up.

So where did the next mole pop its head up?

During the same period, there was a 23% increase in heroin overdose.  

We can add this to the list of reasons abuse deterrent opioids are not the answer.

The study does not establish a causal link between the reduction in opioid scripts and the increase in heroin overdoses, but this phenomenon has been a recurring theme in various reports and studies across the country for some time now.  When Massachusetts Governor Deval Patrick declared a public state of emergency in March of 2014, he cited both prescription opioid abuse and heroin overdoses as grounds for his decision.  Is it any wonder that just a week later, Blue Cross Blue Shield of Massachusetts released an 18 month "check up" on its first-in-the-country program requiring pre-authorization for prescription opioids?  In it, BCBS brags that, starting in July 2012, they decreased claims for short acting opioids by 20% and long acting opioids by 50%.  And yet, the Governor is declaring a state of emergency in early 2014?  Could that be due to at least some portion of BCBS members whose Oxycontin was cut off turning to cheap street drugs?  Perhaps because the insurer, in an effort to stem the tide of prescription drug spend (instead of prescription drug abuse) failed to address the underlying medical issues faced by its members?

PRIUM's own parent company, Ameritox, produced a very compelling piece of research based on our own data that shows:

  • 4 out of 5 heroin users abused prescription drugs first
  • 56% of the time, in heroin positive samples, the opioid prescribed to the patient was not found
  • 66% of heroin users abused both heroin and prescription painkillers in the last month
The most cynical among us in workers' compensation will think (though never say publicly), "Fine with me.  I'm not paying for heroin and I can either settle or cease benefits on this claim with relative ease."  

Those of you that care about injured workers will see this data for what it really is - a warning.  A warning that we must be careful and measured and caring in our approach to issues of prescription drug misuse and abuse in workers' compensation. 

We haven't really solved a problem until we've addressed the underlying issues of dependence and addiction.   

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Monday, April 20, 2015

Don't Be Fooled: Abuse Deterrence Isn't the Answer

One of the consistent themes of this blog is a critique of abuse deterrent formulations of opioids.  While absolutely necessary as one tool among many to stem the tide of prescription drug misuse and abuse, such technology runs the risk of creating a perception of safety among both patients and prescribers that is downright dangerous.

The best discussion I've seen on the topic came out last week on Forbes.  In an article and video by Matthew Herper, the pros and cons, risks and rewards of abuse deterrent opioids are covered quite thoroughly.  The video, in particular, is worth 5 minutes of your time.

And, of course, I would never miss a chance to restate my own position on the matter:

I am 100% supportive of abuse-deterrent formulations of prescription opioids.  These formulations are effective in combating abuse and diversion (at least in the short-term - it seems drug addicts often find a way to crack the code of each newly formulated medication.  But that doesn't mean we should stop trying, nor does it mean we should eliminate the economic incentive for the pharmaceutical companies to develop such technology).  

To me, though, this conversation is a distraction.  While eliminating abuse and diversion would be great for the work comp system, these aberrant behaviors are not driving the bulk of the problem.  The vast majority of cases in which PRIUM intervenes involve legitimate prescriptions being taken as prescribed.  Very little pill crushing.  Very little intravenous injections.  Very little drug dealing.  

The problem as we see it is lack of medical necessity.  In most cases, it doesn't matter if the patient's opioid is abuse-deterrent or not.  If it's medically unnecessary, if it's leading to loss of function, if it's leading to dependence and addiction... it needs to go away.  The doctor will be better educated.  The patient will get better.  The cost of care will go down.  Everyone wins.  

Abuse deterrent technology is great, but if we focus on technology over medical necessity, we will have missed the mark and the crisis will continue.  

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Monday, April 6, 2015

The Fight Comes to My Own Back Yard

Fulton County, Georgia has filed a lawsuit against several of the major drug distribution companies (McKesson, Cardinal, etc.) seeking damages related to the prescription drug abuse epidemic.  I haven't read the full court filing, but it appears this action is similar to West Virginia's approach (i.e., to sue the distributors and not the manufacturers, as the City of Chicago and Orange/Santa Clara Counties in California chose to do).

This suit is interesting for two reasons:

1) It's politically cleaner than the West Virginia law suit.  In that state, the primary law suit left out (at least initially) McKesson and Cardinal, the two largest drug distributors.  Turns out the Attorney General in West Virginia used to be a lobbyist for McKesson and his wife is a lobbyist for Cardinal.  While the legal concept being used by Fulton County of focusing law suits on distributors is similar to West Virginia's, the potential conflicts of interest are absent.

2) I live in Fulton County, Georgia.  I'll have a front row seat for this battle.  My county is a politically, racially, and economically diverse county; but like the rest of America, we have more in common than we have differences.  Among the things residents of Fulton County have in common is that many of us have felt, witnessed, or experienced the impact of prescription drug misuse and abuse.

My community is a lot like yours, probably.  Except that we now have an aggressive and creative legal strategy we're pursuing that may offer a pathway for communities across the country to recoup at least some of the costs we've expended in public health, our judicial system, and our law enforcement agencies.

Or... this could fall flat on its face and prove a waste of taxpayer resources.  I'm not taking a position either way, but I'm fascinated to see how this plays out.

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Wednesday, April 1, 2015

Medical Marijuana: Fear Not

Ben Roberts and David Price, who head up PRIUM's regulatory and compliance consulting team, have authored a great piece on medical marijuana rules and statutes across the country.  The article is data-driven, well-researched, and should have a calming effect on payer organizations concerned about the potential need to reimburse for medical marijuana.

Did you know that of the 24 states with medical marijuana laws, most have either explicit or implicit provisions allowing for commercial payers to avoid reimbursement for medical marijuana?

Did you know that most of these states have a list of allowable conditions that provide a second layer of potential protection for commercial payers?

Did you know that most of these states have medical treatment guidelines that address the use of medical marijuana?

Did you know that the New Mexico cases that have most of our industry concerned about this issue exhibit systemic failure on the part of the payers in those cases to take advantage of these various provisions and protections?

We're not suggesting that medical marijuana is a non-event that deserves no attention.  We're suggesting that smart payers with smart medical management strategies need not fear being overwhelmed with medical marijuana spend.

Check out the full article here.

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