Advanced Opioid Management®
Advanced Opioid Management, a solution from Express Scripts® by Evernorth, is a clinically sound approach focused on driving change in our nation’s opioid misuse crisis.
The Impact of the Opioid Crisis
Lost work, health care costs, and lost productivity as a result of drug abuse cost plans an estimated $81 billion per year.1
The four major dimensions that support a life in recovery include health, home, purpose and community are all being disrupted in today’s complex environment.2 And, sadly, there is still a stigma and internal shame associated with addiction and drug misuse. 90% of people who need substance-use disorder treatment don’t get it.3
1. US Drug Test Centers, https://www.usdrugtestcenters.com/cost-of-drug-abuse.html
2. Substance Abuse and Mental Health Services Administration, https://store.samhsa.gov/sites/default/files/pep12-recdef.pdf
3. American Society of Addiction Medicine, https://www.ama-assn.org/delivering-care/overdose-epidemic/90-who-need-substance-use-disorder-treatment-don-t-get-it
Focusing on Abuse Prevention and Opioid Recovery
Advanced Opioid Management—a nationally recognized solution—maximizes safety across the care continuum, helping shield clients and their members by minimizing early opioid and opioid adjacent therapy exposure, as well as encouraging treatment and recovery for those patients already suffering from opioid use disorder.
This solution takes a uniquely comprehensive and proactive approach—managing new and acute users; short-term or intermittent users; chronic users; and individuals who are misusing/abusing. We address potential behavior and safety gaps at each touch point:
- At the doctor’s office
- At the pharmacy
- With the patient
As a clinically-driven solution, Advanced Opioid Management has been designed to align with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain, which provides guidance to primary care clinicians prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.
At the doctor's office:
Alerts sent when patient activity indicates potential abuse
Prescriber education and peer comparison
Alerts sent suggesting proactive naloxone therapy, where appropriate
Enhanced Fraud, Waste & Abuse lock-in, where appropriate
Alerts sent when opioids are prescribed to patients with mental health or prenatal vitamin prescriptions
Alerts sent when members are demonstrating poor adherence to Medication Assisted Treatment
With the patient:
Informational letter detailing the risks of opioid use
Proactive Express Scripts Neuroscience Therapeutic Research Center® pharmacist outreach, including Medication Assisted Treatment support
Supply of drug disposal bags, when needed, reducing the chance for excessive use or diversion
Case management support for members whose prescription history triggered an intervention that locked them into a single provider or pharmacy to help prevent fraud, waste, and abuse
Mental health, suicide and additional hotline information delivered to patients
At the pharmacy:
New for 2024: addition of over-the-counter NARCAN® Nasal Spray to the program
Supply limits for adults1 and children2 initiating opioid therapy for each of their first 4 fills
Prior authorization required for members starting opioids who accumulate > 90 morphine milligram equivalents (MME)
Prior authorization required for members who accumulate > 200MME
Prior authorization on first fill of a long-acting opioid to encourage a safe start
Safer fentanyl utilization initiatives
Opioid adjacent therapy quantity limits
1. 7-day supply; Not to exceed 28 days in 60-day period
2. 3-day supply; Not to exceed 12 days in a 60-day period
Advanced Opioid Management Proven Success
41%
reduction in the average MME for first-time opioid users with prescriptions above our threshold, with 95% of first-time users dispensed an Rx at or below 90mg MME1
1. Advanced Opioid Management, 90 MME rule – BoB data 9/2019-12/2020
57%
reduction in the average day supply per short-acting opioid claim for first-time users with prescriptions above our threshold2
93%
success rate for patients that were dispensed a 7-day supply or less of medications2
2. Advanced Opioid Management, Short Acting Fill Limit rules – BoB data 8/2019-12/2020