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Prevent, Treat, Support: UnitedHealthcare's Comprehensive Strategy


Opioid misuse has become a national health crisis that needs swift,
effective attention.

UnitedHealthcare is confronting the opioid epidemic, at every opportunity and from all angles. We are joining with care providers and communities and using powerful data and analytics to help prevent opioid misuse and addiction, deliver tailored treatment to those who are addicted, and support long-term recovery.       

Many Americans have or have had a bottle of opioids in their medicine cabinets, but few realize the potential dangers of getting one of these prescriptions filled.
In previous decades, these powerful painkillers were primarily reserved for cancer treatment, serious pain (e.g., after surgery), and end-of-life care. The unprecedented volume of prescription painkillers in the market and the leftover supply sitting in people’s medicine cabinets has triggered illegal use — a major contributor to overdose and a potential gateway to heroin.
 

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Preventing Misuse and Addiction
Too many prescriptions have too many pills or too many days’ supply, falling outside CDC guidelines. Thanks to the vast resources of the UnitedHealth Group enterprise, UnitedHealthcare is uniquely positioned to help address this crisis by connecting efforts across the entire health system and continuum of care.

1. Tracking compliance with CDC guidelines.
UnitedHealthcare actively tracks prescription compliance with the CDC guidelines on dosage, length of prescription and appropriate use (e.g. end of life care and cancer care). In addition, we routinely engage network care providers as part of our work together to support their ongoing education and adherence to the CDC guidelines, sharing with them important reference documents, publishing stories in our monthly Network Bulletin, and having in-person conversations.

2. Implementing prior authorizations.
UnitedHealthcare has implemented prior authorization requirements for long-acting opioids6 to provide coverage for these powerful products to members in alignment with current CDC guidelines. Since implementation within our commercial population in January 2017, we’ve seen:

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In addition, UnitedHealthcare does not require prior authorization on preferred medications7 that are used to treat opioid dependence — including buprenorphine and buprenorphine/naloxone products — or those that are used to treat an opioid overdose, such as naloxone.

3. Implementing safety and use edits.
Our claims processing systems screen for high risk drug combinations in conjunction with opioids. For example, the pharmacist will be prompted to talk with a member and/ or prescriber when a person is already on a medication to treat opioid use disorder (OUD), and will soon be prompted if a person is receiving benzodiazepines, which are used to treat anxiety and a variety of other medical and mental health concerns

4. Implementing supply limits. 
We have placed limits on the quantity of prescription opioids and refills that can be received without consultation so that people do not unintentionally accumulate more opioids than they need. 

5. Educating dental professionals.
Although only 11% of all opioid prescriptions annually are generated by dentists, 47% of all opioid prescriptions for teens (ages 15 – 19) are prescribed by dentists.8 These prescriptions are most commonly associated with wisdom teeth extractions. As young people are one of the highest risk populations for opioid misuse, we are in touch with oral surgeons and dentists in addition to the ongoing educational efforts with all physicians to bring these prescriptions in line with CDC guidelines.


Treating Addicted Members
In addition to efforts around improving access to appropriate medications to treat opioid overdoses, UnitedHealthcare actively promotes and develops care provider networks focused on medication-assisted treatment (MAT), which combines medications with psychosocial support services, as the personalized and evidence-based approach to treatment.

1. Broad access to MAT.
The medications prescribed as part of MAT, including buprenorphine, methadone or naltrexone, block the euphoric effects of opioids, relieve cravings and reduce withdrawal symptoms, which allow the person to focus on treatment.

2. Reducing Neonatal Abstinence Syndrome.
Reducing Neonatal Abstinence Syndrome by decreasing the number of opioids prescribed to pregnant women and increasing the number of members referred to case management for early MAT treatment or other assistance.

3. Collaborating with care providers.
Collaborating with care providers to offer members personalized care plans with access to evidence-based treatment, while promoting the use of Naloxone to decrease the number of overdoses.

4. No Prior Authorization for Naloxone. 
Naloxone (or Narcan®) is a life-saving antidote that can be used when someone overdoses on opioids. UnitedHealthcare does not require prior authorization for naloxone (injectable or nasal spray), allowing greater access to our members. UnitedHealthcare also does not require prior authorization on preferred medications that are used to treat opioid dependence.


Supporting Long-Term Recovery

1. Partnering with communities. 
UnitedHealthcare has launched the Opioid Community Partnership in 10 highly impacted cities across the U.S. to explore ways it can work more closely with local care providers in Accountable Care Organizations, local health departments and community agencies, to deploy market-specific action plans addressing the opioid crisis. This is a pilot program, with the goal of expanding to other cities after evaluation. The action plans focus on:

- Encouraging compliance with CDC guidelines and sharing information on appropriate use of opioids, including avoiding dangerous combinations with opioids such as benzodiazepines and carisoprodol, a muscle relaxant

- Working with pharmacies on appropriate prescribing levels and identifying outliers

- Reducing Neonatal Abstinence Syndrome 

- Promoting and educating on use of naloxone 

- Increasing MAT referrals

2. Reviewing pain treatment alternatives. 
UnitedHealthcare advocates for alternative treatment options for common pain conditions, in accordance with clinical guidelines. We are reviewing benefit plans and copays to provide financially sound alternatives to opioids for members seeking pain relief, including physical therapy, chiropractic and acupuncture.

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3. Using data to get ahead of the problem.
We are using data and analytics to help communities try and get ahead of the problem, such as identifying those most at risk for addiction and helping doctors and pharmacists know when to reach out to individuals who may need support.
About 70% of misused opioid prescriptions were obtained, stolen or purchased from a friend or relative.12 We’re doing our part to help direct them to the intended recipient. Optum reviews prescriptions in real time, and UnitedHealthcare’s technology tracks member prescriptions retrospectively for the most commonly misused drugs, including opioids. The following areas are monitored:   

- Potential for drug diversion, such as reselling a prescription 

- Potential for false medical claims (e.g., multiple doctors writing same prescription) 

- Potential for patient harm, such as dangerous interactions

Such analytics include noting doctors with high rates of opioid prescribing, pharmacies with a high rate of opioid dispensing, and patients seeking prescriptions from multiple prescribers or pharmacies. Leveraging our data and analytics in this way can help predict and prevent opioid misuse as well as identify patients at greater risk.

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References:

1. American Society of Addiction Medicine, Opioid Addiction: 2016 Facts and Figures, 2, http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf.
2. Understanding the Epidemic: Drug Overdose Deaths in the United States Continue to Increase in 2015. Centers for Disease Control and Prevention. Accessed Aug. 25, 2107.
3. Florence CS, Zhou C, Luo F, Xu L (2016). The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care: Oct 2016 – Volume 54 – Issue 10 – p 901–906.
4. IMS Health, National Audit (NPATM). Cited in internal document: Preliminary Update on Opioid Pain Reliever (OPR) Prescription Rates Nationally and by State: 2010-2013. URL: https://www.cdc.gov/drugoverdose/opioids/prescribed.html
5. Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and non-medical use of opioids: a ten-year perspective. Pain Physician. 2010;13: 401–435.
6. UnitedHealthcare commercial business as of 1/1/17. This is not allowed in Medicare plans.
7. On UnitedHealthcare’s commercial prescription drug list (PDL).
8. UnitedHealthcare commercial business.
9. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. March 17, 2017. Available at: https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm.
10. Centers for Disease Control and Prevention. Opioid Overdose, Understanding the Epidemic. Available at: https://www.cdc.gov/drugoverdose/epidemic/index.html.
11. According to research performed by Optum (2017)
12. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Sept. 2014.