National opioid trends indicate that 4.5 million Americans have a substance use disorder with prescription pain killers.1 The economic impact of the opioid epidemic is staggering, with $55 billion in health and social costs related to prescription opioid abuse each year, and $20 billion in emergency department and inpatient care for opioid overdose.2,3 Since 1999, the rate of overdose deaths involving opioids has nearly quadrupled, and over 165,000 people have died from prescription opioid overdoses.4
For over a decade, UnitedHealthcare has been investing in multi-dimensional programs to help reduce the abuse of opioids while providing patients with both temporary and chronic pain access to safe and effective treatment — including non-opioid options. We have a number of programs and policies in place to help prevent the misuse of opioids, and provide quick and appropriate access to opioid addiction treatment.
Our efforts have made a tangible impact on helping reduce the potential over-prescribing and overlap of opioid treatments. In 2015 alone, we had a 93 percent success rate with our Retrospective Narcotic Overutilization program.5
Our work is far from done. UnitedHealthcare continues to invest resources into programs aimed at both the prevention and treatment of opioid addiction, taking into account the Centers for Disease Control and Prevention (CDC) recommendations. By connecting physicians, pharmacists, drug manufacturers, government, health plans, and clients and consumers, we strive to build a modern, high-performing, simpler health care system that works better.
UnitedHealthcare's opioid initiative includes:
Prevention of Opioid Overutilization
Several years ago, UnitedHealthcare successfully implemented a medical necessity program that requires prior authorization for long-acting opioids. This program has evolved over time and now aligns with the requirements recommended by the CDC guidelines. Long-acting opioid supply limits have also been established and are based on morphine equivalent dosing. These limits are only applicable to members with non-cancer or non-end of life pain.
Drug Utilization Review
Using our deep analytics capabilities and data, we are able to help identify individuals who may be at risk earlier in the progression of this disease so that intervention can occur sooner and adverse outcomes can be reduced.
- Retrospective Narcotic Overutilization Program
For the past 10 years, UnitedHealthcare has expanded its Retrospective Narcotic Overutilization program that identifies members who are at increased risk of opioid dependence due to a high number of prescriptions from multiple doctors and pharmacies — allowing a coordinated and holistic approach to prescribing patterns. Consider the following trends among our commercial health plan members in 2015, based on members identified through use of our Retrospective Narcotic Overutilization program:
- 41 percent decrease in the number of opioid prescriptions written
- 45 percent decrease in the number of physicians prescribing opioids
- 41 percent decrease in the number of pharmacies dispensing opioids
- Pharmacy Lock-in Program
UnitedHealthcare utilizes a "Pharmacy Lock-In" program to create a coordinated view of prescribing patterns. Once enrolled in this program, members must obtain their prescriptions from a single pharmacy, reducing the likelihood of overprescribing or conflicting prescriptions. Members are identified for the "Lock-In" program through our Retrospective Narcotic Overutilization program, fraud/waste/abuse program, as well as physician and medical director referrals.
Through our drug utilization review process, we can identify members who have started opioid dependence therapy to reduce their reliance on opioids, but continue to receive an opioid medication from one or more prescribers. This important step allows us to proactively notify physicians about a possible relapse, and help encourage intervention.
In addition to member level drug utilization review, we continuously data mine pharmacy and medical claims to help identify outlier prescribers. Our focus has been on excessive dosing of opioids, excessive duration of opioids, and dangerous combinations of opioids with central nervous system depressants such as benzodiazepines. Through peer comparison reporting based on prescriber specialty, we conduct a multilevel approach to outreach and intervention. Some providers will modify their practice with a simple notification that lets them know where they stand among their peers. Others may require peer to peer outreach and education through academic detailing.
In partnership with our Controlled Substance Drug Diversion Program team, we also help identify prescribers that are suspected of engaging in diversion. This program helps support our Drug Enforcement Administration (DEA) and Health and Human Services (HHS) Office of Inspector General (OIG) partners.
Quick Access to Treatment
On March 1, Prior Authorization was eliminated for preferred medications on UnitedHealthcare's commercial Prescription Drug Lists (PDLs) that are used to treat opioid dependence, including buprenorphine and Zubsolv®. Naloxone, which is used to treat opioid overdose, is also covered without Prior Authorization.
Proactive Interventions and Support
UnitedHealthcare provides benefits coverage for medication assisted treatment so that people who develop opioid dependence can receive the support they need. Patient support is among the most important services we can provide for individuals fighting addiction.
- Patient Substance Use and Treatment Helpline: We provide access at no additional cost to a confidential patient substance use and treatment helpline with specialized clinicians who provide treatment advocate services 24 hours a day, 7 days a week.
- Holistic, Whole-Person Approach: We also have one of the largest networks of medication assisted therapy providers and are actively integrating medical, behavioral and pharmacy treatments to enable a holistic, whole-person approach to help reduce opioid abuse and dependence.
- Live and Work Well: Our dedicated website that answers commonly asked questions and provides access to help with a single click or call.
- Additional Public Resources:
Learn more about UnitedHealthcare's opioid initiative by contacting your UnitedHealthcare representative.
1 Kolodny, A. et.al. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health. 36:559-574. DOI: 10.1146/annurev-publhealth-031914-122957.
2,3 Pain Med. 2011;12(4):657-67. 2013;14(10):1534-47.
4 CDC Vital Signs, 60(43); 1487-1492.
5 Success rate is defined as the percent of unique members no longer meeting criteria in the most recent quarter.