The agency that manages health care for California’s massive state workforce is reporting a major reduction in opioid prescriptions, reflecting a national trend of physicians cutting back on the addictive drugs.
Insurance claims for opioids, which are prescribed to help people manage pain, decreased almost 19% in a single year among the 1.5 million Californians served by the California Public Employees’ Retirement System. CalPERS manages health benefits for employees and retirees of state and local agencies and public schools, and their families.
Most notably, doctors reduced the daily dose and duration of opioid treatment: The number of new users who were prescribed large doses dropped 85% in the first half of 2018 compared with the same period in 2017, while new users prescribed more than a week’s supply dropped 73%, according to new CalPERS data.
“These reductions are substantial,” said Beth McGinty, an associate professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. “They signal a reduction in the overprescribing practices that have driven the opioid epidemic in the U.S.”
What’s unclear, however, is how the reductions in prescriptions are affecting patients’ pain, she said.
Every day, 115 Americans die from opioid overdoses, and about 40% of those deaths are caused by overdoses of prescription drugs. About one-quarter of the millions of patients who take the medications for chronic pain misuse them, the National Institutes of Health says.
Prescription opioids — which are frequently prescribed for cancer patients and for orthopedic and dental pain — include hydrocodone, oxycodone, fentanyl, oxymorphone, morphine, codeine and others.
CalPERS has spent more than a decade trying to reduce prescription opioid use among its enrollees, working with health insurers and other state agencies to identify doctors who prescribe abnormally high amounts. In 2017, OptumRx, which manages CalPERS members’ pharmacy benefits, adopted a policy that includes limits on the quantity of opioids prescribed and requires prior authorization for some drugs.
CalPERS is the second-largest public purchaser of health benefits in the nation after the federal government, and medical trends among its members are often reflected nationally.
Indeed, the data showing a decline in opioid prescriptions among CalPERS members mirrors a nationwide drop that has been reported in all 50 states.
About 22% fewer opioid prescriptions were written in the United States from 2013 to 2017, dropping from 251.8 million to 196 million, according to the American Medical Association, the nation’s largest physician group.
A March study by researchers at the federal government’s Centers for Disease Control and Prevention revealed a 13% decline in average opioids prescribed per person from 2016 to 2017. Maine, Massachusetts and North Dakota have experienced the biggest drops over the past decade.
One major factor is that many health insurers have imposed limits on prescriptions, as recommended by the CDC in 2016. The CDC advises doctors to prescribe new users no more than a seven-day supply and to keep daily doses under the equivalent of 50 morphine milligrams in an effort to prevent overdoses and new addictions.
In addition, the AMA created a task force in 2014 that has encouraged doctors to “start low and go slow” and use the drugs only if the benefits exceed the risks for a patient. The association also is offering doctors education programs on pain management.
Opioid medications act on receptors in the brain and spinal cord to reduce the intensity of pain perception, but they also activate regions of the brain that trigger euphoria, which underlies their potential for abuse.
Declines in prescriptions have not yet led to reductions in deaths, said Dr. Patrice Harris, president-elect of the AMA and chair of its Opioid Task Force. “Reducing opioid prescriptions is important but will not by itself reverse the epidemic,” she said. “We will reach a tipping point when opioid-related mortality begins to decrease.”
Medical experts also warned of unintended consequences of fewer opioid prescriptions: More people may suffer unmanaged chronic pain, and some may resort to illegal opioids, such as heroin or street versions of fentanyl. About 50 million Americans experience chronic pain.
“The focus on reducing opioid prescribing has likely left a large void in access to pain care,” Harris said.
Even as insurers set limits on opioids, they have not increased access to other pain care options, she said. “If policymakers solely focus on limiting access to prescription opioids for pain relief without increasing non-opioid options, the result will be increased patient suffering.”
The CalPERS data represents a cross section of patients throughout California who are enrolled in Blue Shield, Kaiser Permanente, Anthem Blue Cross and other health plans.
Reductions in their opioid use were across the board: The doctors cut back on numbers of people taking opioids for long periods of pain, but also how much people took daily. Prescriptions exceeding two weeks fell almost 32% from January to June 2017 and the same period in 2018. Daily average doses declined 14%.
“These are very positive numbers,” said Kathy Donneson, chief of CalPERS’ Health Plan Administration Division. “But we’re all going to keep working on it. Opioids are still a national crisis.”
CalPERS members are still being prescribed considerable volumes of the drugs. For instance, 34,321 patients were prescribed opioids in the first half of 2018, according to the data. Of those, 1,168 were prescribed doses that are considered large — over the equivalent of 50 morphine milligrams per day.
Health experts said it’s important to wean people off the drugs properly, prevent relapses and ensure they don’t switch to heroin.
The surest sign of success, Donneson said, will be when patients with many types of chronic pain, such as knee or back pain, are “kept pain-free in other ways” and when opioids are reserved for patients who need them the most, such as those with cancer or in hospice or post-surgery care.
“We’re not there yet,” she said.
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