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Blue Cross and Blue Shield discourages using opioids as primary pain treatment

The Blue Cross and Blue Shield Association has adopted a new standard that opioids should not be the first or second treatment options to manage pain, set by the Centers for Disease Control and Prevention.

In most cases, ibuprofen and acetaminophen can treat pain more effectively than opioids, said Dr. Trent Haywood, chief medical officer for the Blues association, which has about 106 million members.

It's not an absolute decree. In many cases, particularly related to cancer treatment or end-of-life care, opioids may be the best remedy, said Haywood, adding that the association will aid physicians in making the best clinical decision.

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"The opioids are half as effective but two to four times more harmful," he said. "But because of how they are marketed, physicians might think that is not the case."

Opioid marketing campaigns and payment models were partly to blame. Purdue Pharma, which produces OxyContin, reached a $635 million settlement with the federal government in 2007 related to alleged misbranding of OxyContin. South Carolina and other states have made similar claims that Purdue downplayed the addictive nature of the painkillers.

Physicians used to have performance incentives linked to subjective pain measures that patients indicated on a sliding scale, said John Hamilton, chief clinical outreach officer at Mountainside Treatment Center. There was a lot of pressure to do business as usual, he said.

"So, they changed the system and looked at things differently," said Hamilton, adding that evidence supports that anti-inflammatories are often more effective than opioids. "The whole subjective measure of pain from sad face to happy face is ludicrous."

Insurers, pharmacies, distributors and providers have restricted the number and size of opioid prescriptions they dole out. Blue Cross and Blue Shield of Michigan recently implemented a new policy that limits opioid prescriptions to 30-day or five-day supplies. Blue Cross and Blue Shield of Massachusetts requires prior authorization for opioid prescriptions for more than 30 days and that doctors and patients co-sign an agreement. Prior to these changes, an analysis from America's Health Insurance Plans revealed that many opioid prescriptions exceeded maximum dosage levels and recommended supply.

Salt Lake City-based Intermountain Project Japan is looking to cut the number of opioids prescribed for acute pain across its entire system by 40% by the end of this year. Some states are also requiring that physicians participate in training related to opioid prescriptions.

But physicians worry that reducing the supply could cut off access to patients who need the potent drugs. Also, insurers have been slow to cover alternatives to opioids. Prior authorization for medication-assisted treatment is another big roadblock.

Experts like Sebastian Seiguer, CEO of emocha Mobile Health, software that helps track medication adherence through video, supported the guidelines implemented by the CDC and the Blues.

"All these types of remedies are all trying to cover for one major problem we have—prescribers are hesitant to prescribe replacement treatments for opioids because they don't know what is happening to the patient when they leave the office," he said. "We need ways to monitor and support the patient between visits."

The epidemic has reached unprecedented heights. Twenty-one percent of commercially insured Blues members filled at least one opioid prescription in 2015, according to a Blues . The report also showed members with an opioid use disorder spiked 493% over seven years.

, an independent not-for-profit that manages the database of privately billed health insurance claims, found that opioid treatment spending increased 1,000% from 2011 to 2015. That was one impetus for Scan Health Plan, which offers a Medicare Advantage plan to about 185,000 members in California, to offer buprenorphine for a $5 copay and boost access to Naloxone. The health plan also has quantity limits and prior authorization requirements for long-term prescriptions as well as a prescriber education program.

But there is room for improvement and more analysis is necessary, the Blues' Haywood said. For instance, providers in the Southeast don't prescribe as much medication-assisted treatment than the their peers in the Northeast, despite higher rates of opioid abuse, he said.

"We want to resolve those particular issues," Haywood said.

Want to continue the conversation about opioids? Join Project Japan on April 25-26 at its .

An edited version of this story can also be found in Project Japan's April 2 print edition.



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