Midwest Employers Aim to Sway Opioid Prescribing Habits

Published in December 26, 2019, issue of Radar on Drug Benefits

Thirty-six percent of the employers that belong to the Chicago-based Midwest Business Group on Health (MBGH) have made benefit design changes to restrict access to opioid analgesics through their PBM, according to a Dec. 10 webinar organized by the nonprofit. Still, 29% of its members aren’t considering such changes and 21% don’t know if they will make these changes to their benefit designs, signaling there may be more work to do to address the opioid crisis.


That’s occurring while opioid deaths in Illinois continue an aggressive march upward, despite the fact that the opioid prescribing rate has been trending downward since 2012. While progress has been made, employers must continue to work with payers and PBMs to change their drug-benefit designs, Denise Giambalvo, vice president of MBGH, tells AIS Health.


MBGH is composed of groups of midsize and large, self-insured public and private employers; its 125 members cover 4 million lives and spend more than $4.5 billion yearly on health care benefits.


Bundled Payments Can Be a Barrier

Giambalvo tells AIS Health that physicians should stop prescribing opioids after all surgeries. The challenge is opioids are included in the payment bundles that health care organizations have negotiated with health insurers, which will pay for non-opioids outside these bundles, she says.


In addition to limiting opioid pain relief to three days for post-surgical pain relief, Chicago-based The Boeing Co. has reduced the milligrams of opioids patients receive, she says, suggesting that is another helpful solution.


According to the U.S. Centers for Disease Control and Prevention, the overall national opioid prescribing rate declined from 2012 to 2017, when it fell to a 10-year low of 58.7 prescriptions per 100 people. But the federal agency highlights that opioid prescribing rates vary widely across different states. For example, Alabama has the highest rate of opioid prescriptions, followed by Arkansas and Tennessee.


Heather Sell, Pharm.D., national employer medical outcomes specialist at New York-based Pfizer Inc., told webinar attendees that chronic pain is the most prevalent among all common conditions. Specifically, 100 million patients present with chronic pain, whereas 27.1 million present with cardiovascular disease, 25.8 million with diabetes and 13.4 million with cancer.


One construct that payers and PBMs can use when deciding about pharmacological options is to focus on the three different types of pain, Sell said. These include:


✦ Nociceptive pain: Rheumatoid arthritis, osteoarthritis and gout are examples of conditions where patients experience chronic pain that’s related to somatic or visceral tissue damage caused by trauma or inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are recommended to treat this type of pain, whereas prescription opioids may be appropriate if first-line treatment is unsuccessful.


✦ Neuropathic pain: Painful diabetic peripheral neuropathy and postherpetic neuralgia are examples of conditions where patients have pain related to the damage of peripheral or central nerves. Antiepileptic drugs (AEDs), serotonin and norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) are appropriate first-line treatment for these patients, whereas prescription opioids may be appropriate if first-line treatment is unsuccessful.


✦ Sensory hypersensitivity: Fibromyalgia is one such condition where the patient has chronic pain that’s not associated with identifiable nerve or tissue damage. Instead, “persistent neuronal dysregulation” is thought to be the cause of this pain. Opioid use should be avoided among these patients, for whom AEDs, SNRIs and TCAs are appropriate.


Still, Sell acknowledged that some patients experience chronic pain in a “mixed-pain state” that can cross nociceptive and neuropathic pain types, in addition to sensory hypersensitivity. A good example of this is with chronic lower back pain.


As they analyze claims with an eye toward changing benefit designs, employers should focus first on highlighting the most common conditions and then combine health plan and PBM data to assess treatment patterns, said Sell, who advised this approach:


✦ Ensure alignment with clinical guidelines and consider opioid prescriptions only after the failure of, or along with, first-line non-opioid and non-pharmacologic therapies for pain.


✦ For the treatment of acute pain, employers should consider working with payers and PBMs to limit access to opioids for three to seven days and make available immediate-release formulations rather than long-acting opioids, which should only be prescribed for patients with severe pain that requires 24/7, long-term treatment and where other treatment options have proven unsuccessful.


Contact Denise Giambalvo via spokesperson Cary Conway at

by Aine Cryts