Articles, Blog

Blue Promise: Combating the Opioid Epidemic (Part 3)

December 29, 2019


[Music] DAN: In our previous
segments we discussed some of the policies
officials have put in place as a result of
this crisis and how they aren’t
necessarily effective. If current policies and
regulations aren’t working what can be done and how
are we addressing the problem in Texas? Thanks for joining us fo
this edition of Blue Promise. I’m Dr. Dan McCoy and
I’m the President of Blue Cross and Blue
Shield of Texas. I’m here with
Ross Blackstone. ROSS: Thank you Dr. McCoy.
We have two guests here with us today
Dr. Leanne Metcalf is our Executive Director
of Planning and Research for Blue Cross Blue
Shield of Texas and Phiyen Tra is a
Pharmacist and Director of our Clinical
Program so if you guys would bear with me a little
bit I’d like to share some statistics to kind of
put this whole opioid conversation in perspective,
specifically for Texas to localize it right. So
Texas has only ranked 48th out of 50 for opioid
deaths but that’s a little misleading because four
Texas cities are actually at the.. ranked in the top 25
cities for opioid deaths. Texarkana is actually #10.
Amarillo is 13. Odessa and Longview are all
listed among the top cities in the country
for opioid deaths. So this conversation really
is hitting close to home and on the economic side
of things and how it affects our business environment,
25 percent of workers compensation
costs are related to prescriptions was
related to opioids.. 25 percent.. and most people who use
opioids with workers compensation for
more than three months they never even
returned to work. So this is impacting
our economy. The cost of opioid deaths is
about $800,000 per person and in 2015
that equated to five hundred and
four billion dollars nearly three percent
of our GDP. So this is an issue
that’s not just… it’s not just a
health crisis right this is a business crisis
this is an economic crisis that’s affecting the
United States and especially us here in Texas. So with
that in mind Phiyen we talked a little bit
already about what Blue Cross and Blue
Shield of Texas is doing to address this problem.
Can you elaborate a little bit more about what we’re
doing here in our state? PHIYEN: Sure I just say give
some historical background back in as early
as 2013 we became more aware
of the opioid epidemic even before it started hitting
all the news outlets and becoming more
publicized and we gathered a group of leaders within
our organization to come together and just brainstorm
ways to help our members who are combating this
type of addiction and at the time we had representation from Pharmacy,
from Medical, from Special
Investigations, Case Management,
and Behavioral Health, and we put everybody
together and we said we need to come up
with a solution, it might not be the
perfect solution but it’s something that
will help us move forward in addressing this
issue and so the Controlled Substance
Integration Program was born pretty much
in 2014. DAN: So tell us
a little bit about that program and what the
components are. PHIYEN: So there are two
different components within CSI
there’s the Member Centric
Program and the Provider
Centric Program. Within the
Member Centric Program we have ways to use our
data to identify members who may basically benefit from
additional interventions or outreach and we
work together with medical directors to
perform peer-to-peer conversations with
the members prescribers to better understand
what their regimens are what their plan is and
then also to address any safety concerns and
issues with the prescribers. DAN: Does this actually
occur early on in the use of these drugs with
a member or do you find yourself often it’s..
it’s too late they’ve actually
been on these drugs for a while now. PHIYEN: When the
program first started we ran across so
many different instances of situations
where the member has been on high
volumes of medications they’ve been seeing
multiple prescribers they’ve essentially
been doctor shopping and then also going
to different pharmacies now that type of behavior
is very interesting to us because it’s sends
red flags as to you know perhaps this person is
aware of their situation that maybe they’ve kind
of realized that hey I’m now trying to
kind of skirt under the radar a bit to
continue using these medications because
maybe I went to a previous pharmacy and
maybe the pharmacists there was asking me too many
questions and I got uncomfortable so I
decided to go to a different one. DAN: Do you think,
to some degree I would think
there’s probably I think there’s a
lot of scrutiny right now on opioids so there are
legitimate reasons for members to have pain
do you think that they… that there’s some
concern when you take the prescription to
the pharmacy is there an automatic
thought process that is this fraudulent or not
or do you think these drugs are just filled
and handed out? PHIYEN: Well I
think definitely we don’t want to you know
shame a patient who might be going through a
situation where they do need additional
help and we do definitely want to support the
treatment of pain and it’s something that we don’t
want to create barriers towards. ROSS: 87% of people who use
opioids use them properly. PHIYEN: Right. Yeah so
it’s it’s not that we want to create these programs
as obstacles in the treatment of pain
we definitely want to use these programs as
a way to coordinate better with the members
prescribers and then also talk to the
members directly and offer them with
additional resources to help them in
their situations. DAN: Okay so what about
the provider side? So tell me a little bit
about how those interactions go with a provider community.
Are they receptive usually? PHIYEN: Yes, surprisingly
so we have had some good feedback on our provider
program basically what we’ve been doing
is comparing different prescribing habits for
one prescriber against those of their peers and so in
a way they see a snapshot or report card of how they’re
doing and how they might be an outlier in some
situations and in addition to what we send out
we do educate them around the state
PDMP which is the prescription drug
monitoring programs that are available in
which prescribers are able to log on and basically
see a full view of a member’s drugs that
they’re filling. DAN: So I guess the issue
here’s the same thing you want providers
to appropriately treat pain but at the same time you
want them to be aware of the risk of these drugs
for addiction. PHIYEN: Right. DAN: For the most part. ROSS: I think it’s worth
noting to repeat most of the providers have good
intentions and when they are working with us and
we’re working with them but it is worth noting that
there’s a couple of bad apples out
there I know our company recently
prosecuted one doctor who is over prescribing
to his patients six people
were killed because of his
over prescriptions and he’s actually now
being prosecuted so we’re pursuing those
and speaking about prosecutions I think it’s also
important to point out that it’s been in
the news lately that some people who are
who are dying of opioids prosecutors are
going after their friends and their family members
and not just the doctors people who are enabling
opioid use and sharing medications that they
shouldn’t be sharing so I think that’s
a good takeaway if you get a
prescription that’s for you
you don’t really want to be sharing it
with somebody else. LEANNE: Right, yeah, and the
good thing there with some of the other programs
that are in place and that some of our pharmacy partners are
instituting take-backs so if you are done taking
your opioid medications you can go to those
different pharmacies and just get rid of all
there you know right a safe, contained,
secure arena where someone else in your
family won’t have access to it some you know it’s akin to
someone on likened it to you know having essentially
a weapon in your house right you’d lock it up
you keep your knives somewhere safe
you know you keep things away
from your kids and others that could harm themselves so
same thing with this type of with these medications
keep them somewhere safe while you are using them
and then when you’re done you can go in and drop them
off at the pharmacy. ROSS: So what’s
the state doing? The state of Texas
I know has been doing a lot of things
LeAnn can you enlighten us? LEANNE: So I
would definitely say that Texas and firstly
I do need to give credit to the Texas legislative
group because in 2015 when the hydrocodone
schedule change happen and we saw scripts go
down in different states but we saw the strength
the dosage that morphine equivalent dose go up
the day supply go up when we looked
state-by-state Texas is actually lower
and almost flat so their increase was
slight as compared with other states when we saw
the overall increase so I would say that
Texas was pretty good with their local
interventions and their local policies and
in helping ensure that we didn’t have this
the same level of unintended consequences in
other states. ROSS: And I know
that just this past May Texas received a grant
from the federal government for twenty seven point
four million dollars to address opioids and
the federal government expects that’s gonna actually
impact 14,000 people across our state. LEANNE: Yeah and, and
also trying to create more treatment centers because
we talked about providers and supporting our
providers but you know especially you
know PCP settings or surgical settings
they are overwhelmed and they’re not
necessarily trained to manage an addict
or manage someone and help titrate
them off of a certain level
of opioids so to have more treatment
centers will also help those providers refer
patients into somewhere that they can help
get help as well. DAN: But clearly that’s
the end state we want to avoid right
we really don’t want to get to a point where
someone’s addicted so there still needs to be
significant education and really kind of an escalation
of the proactive stance of the provider community to
stand up and say there’s got to be some things done
to make sure that this doesn’t happen to normal
routine patients that get addicted to these
medications because they take them for a
legitimate reason. ROSS: And so and part
of that is just it’s is the onus lies
on the providers on the doctors but it also
lies on insurers and on the good community
and the individual as well. I think it’d be helpful if
you guys could walk us through what people
should pay attention to if they go to
their doctor and they might get prescribed an opioid
I mean it’s not necessarily something
that you want to be terrified of because it’s
gonna kill you sometimes it’s needed
we had talked earlier about how there’s two
different types of pain and how opioid might play
into pain medication or pain treatment.
Phiyen could you kind of walk us through that
what make us… helps us identify some questions
maybe that we should ask whenever we approach
this medication for ourselves. PHIYEN: Right so just I’m
putting myself in a member situation you know
going to prescribers office some of the questions that
I would ask are you know are there any alternatives
that I can use before I receive this opioid and
also how long do I expect to be on this
medication for? How will I be tapered off
of the medication so basically how does the
prescriber plan to decrease treatment as my pain heals
and then also if there are other alternative methods
of treating the pain such as you know
the massage therapy, acupuncture, over-the-counter
medications, and things like that. ROSS: Are opioids
typically better for acute pain for something that’s
just kind of instant and might not last that
long or is it better for chronic pain and
something that might be a long-standing pain
that you have to deal with is it better or worse
for one or the other? PHIYEN: I think we as
Leanne mentioned in this study where we looked at patients
who were prescribed opioids after surgery that’s an
appropriate situation however the fact that
they continued to stay on their opioids years
after surgery that’s definitely
a concern. ROSS: Okay interesting
conversation. Sorry go ahead… LEANNE: Oh no, I was just
going to say that before those members when
they’re having that conversation with their provider
as Phiyen alluded to before it’s also being open
about is there something in the family history
that might indicate that… ROSS: Addiction. LEANNE: …there might,
there might be the odd the opportunity to be addicted and also
because we talked about those opioid naive patients
the ones that had, didn’t have access to
opioids before but if you aren’t opiate
naive and you had been on opioids at one
point in time before also being aware of that
the dosage you are at it doesn’t mean that the
second time around you need to match it cuz that’s
where we do see a lot of overdoses as well the body
got used to not being at such a high dose and they
immediately go back to the dose level or even higher
than they were at before and then they have
an overdose event so you definitely want to
have that open conversation to the best of your memory
to the best of your history you know track things so
that you don’t have a situation like
that as well. DAN: Well it’s been a
fascinating conversation. So one thing I want to
kind of talk on before we leave is the fact that
we don’t want to… we don’t want to make
another public health decision that has
an adverse consequence and I think naturally
when you think that drugs are over prescribed or
people have too much opportunity to
get something the natural
assumption is we’ll just turn it off
right shut it all off don’t make it available
but I think that has some adverse consequences too
you want to talk a little bit about that. LEANNE: And Phiyen will
have some additional statistics on this as well but we find
that for individuals that were in stricter
programs previously where they were identified
as opioid abusers then you cut the source off
they found another way to get access and in that
uncontrolled environment then you had those
consequences of more overdoses or even deaths
so you want to be able to look at things in
a responsible way for those individuals
and then also like we talked about
someone’s in pain you want to be sure
that they get help in a responsible way and
just kind of cutting things off and ending
things means that you might take
other measures. DAN: Yes, let’s
talk about this so one thing if you cut
the drugs off right number one you could
cause pain in an individual that is
taking the drug for a legitimate reason. LEANNE: Yep. DAN: And that’s not
something anybody really wants to do because
nobody wants to leave a patient in
pain. The second thing is they
could start to drug seek because they’re concerned
about their pain which could result finding a pill
mill or someone that prescribes a lot of
medication and not properly
supervised. LEANNE: Right. DAN: But there is the
risk actually that they use illegal drugs if they
can’t get a legitimate source you know tell me a
little bit about that. PHIYEN: Yes we have read
some articles in which patients then seek illegal
drugs such as heroin for an example and… DAN: Which is really uncontrolled. PHIYEN: Right, right. DAN: And really in a much
higher risk of death from overdose. PHIYEN: Right, and another safety
point to bring up is you know if a doctor writes an
opioid prescription for you and you share it
with the next person saying oh I have a
medication that treats pain that creates a
very unsafe situation and I think it’s
very important for our members to be
aware of that something in which o
you think you’re trying to help somebody
alleviate their pain may actually put
them on the course for addictions. ROSS: 75% of opioid abusers
begin with prescriptions that were not
prescribed for them. DAN: Well thank you for
being here and I think what you’ve demonstrated
is why this problem is so complex because there
are issues with the providers with writing the medication
the dosage of the medication the strength of
the medication the addictive qualities,
the fact that people legitimately have pain
and the fact that there’s an illegal drug
market too it really creates a complex public health
challenge and I really appreciate you
coming here today and sharing some insight
and understanding about the research that you’ve
done and telling us a little bit more about
how to help make this problem better. Thanks for being here for this episode
of Blue Promise [Music]

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