PARTNERSHIP HEALTHPLAN
Managing Pain Safely Marshall Kubota, MD
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mid all the grim statistics ab out pr e s c r ip t ion d r ug abuse, here’s a happy one: Partnership HealthPlan of California has achieved a 40–50% reduction in opioid use throughout our service area since 2014. PHC is a nonprofit health plan that began administering the MediCal benefit in Sonoma County in 2009; the plan also administers Medi-Cal benefits in 13 other Northern California counties. There are more than 110,000 PHC members in Sonoma County, and they account for 22% of the county’s population. In 2013, Medi-Cal published a retrospective analysis of opioid use in its fee-for-service patients from May 2010 to April 2011.1 During that period, 12% of Medi-Cal FFS patients used opioids. Within the 40–64 age group, more than a third (34%) received at least one opioid prescription; for the 19–39 age group, the rate was 18%. Opioid drugs accounted for 5.5% of all retail claims and 4.5% of total dollars paid. Half of all opioid claims were for hydrocodone. There are many consequences for such high prescribing rates. At the capstone of the pyramid of opioid use are the overdoses and deaths. Sonoma Dr. Kubota, a Santa Rosa family physician, is a regional medical director for Partnership HealthPlan of California.
Sonoma Medicine
County drug overdose mortality rates (12/100,000) are slightly more than the state average (11/100K), but several PHC counties had far higher death rates, including Lake (46/100K), Humboldt (33/100K), and Mendocino (20/100K).2 Beneath the capstone are many patients on dangerously high, ineffective doses that are doing more harm than good. Lacking objective measurement of pain, clinicians are uncertain who has pain, how much, and whether the patient is abusing or diverting medications. Much of the problem began in an earlier era, and younger clinicians feel like they have inherited it. True in part, but an analysis by PHC showed that over six months’ time in 2014, approximately 30% of PHC members already receiving opioid doses greater than 120 MEDs (morphine equivalent doses) got a dose increase during that period.
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HC began addressing the opioid pre sc r ipt ion problem w it h a meeting of local medical directors in 2010. In fall 2012, the health plan brought the problem to the front of the local health care stage by sponsoring conferences that featured local pain specialist Dr. Andrea Rubinstein. In 2013, PHC began the Managing Pain Safely (MPS) initiative, which has led to the 40–50% reduction in opioid use mentioned earlier. PHC developed short- and long-term goals for the MPS initiative with input from internal and external advisory
committees, along with results of a prescriber survey. Pharmacy policy was the primary focus. In October 2014, PHC implemented a 120 MED/day threshold for individual medications and a 40 mg/ day limit for methadone because of QT prolongation concerns. Refill periodicity was narrowed to prevent 13-month refill years. Prior authorizations were required for drug escalations. Such escalations were considered a temporary measure. Meanwhile, PHC provided medical offices with up-to-date information on the prescription opioids obtained by Medi-Cal patients who are assigned to that office. Patients with high-dose opioids require either dose justification or plans for dose reduction to safer levels. In addition, PHC made certain non-opioid treatments available, including previously restricted medications, podiatry, chiropractic, acupuncture, and behavioral health. PHC also participates in county-initiated efforts to reduce prescription opioid use. PHC restricts opioid availability in each new county it administers. Member assignment to a single medical office sharply curbs doctor shopping, and Oxycontin is not on the PHC formulary. Clinicians are using the new PHC policies as a foil for their difficult discussions with patients regarding dose limitations and reductions. The policies can also be used to recommend alternative therapies. Best practices and Summer 2016 11