Now that you know where to look for data related to pain management, the next step is figuring out what to look for. Start by identifying data on health care utilization for the most common and costly pain conditions impacting your population. If a data management vendor is used, they can pull this data showing related medical and pharmacy data.

For more information, see Appendix A (pages 16-18) in the Guide.

• List of standard ICD-9-CM codes for painful conditions by category¹ (there is no standard list published for ICD-10-CM codes)
• List of other conditions that are often common or costly to serve as a comparison

Health Plan/Medical Benefits

Request data and analysis from your health plan in order to evaluate inpatient, outpatient, drug and emergency room (ER) claims for:¹

• Multiple admissions for a pain diagnosis
• Opioid abuse, dependence or poisoning¹
• Dependence on central nervous system depressants (e.g. benzodiazepines)

Work with your health plan to monitor health care utilization patterns for patients diagnosed with a painful condition. This may include identifying:¹

• The utilization of sites of care for treatment of pain (e.g. inpatient, outpatient, emergency room, urgent care)
• The percent of the population that has a diagnosis for a pain condition

Review all health plan data collected in context with PBM data to begin developing an overall picture of the impact of pain on your population.¹

Pharmacy Benefits Manager (PBM)

Gather aggregate data from your PBM on pain management prescriptions. Note that some PBMs may have in-house programs that include such monitoring. Check to see if there is an additional cost to provide this analysis.¹

Review patient profiles for multiple similar opioid medications:¹

• Review the number of prescribers writing more than one type of pain medication for the same patient
• Review the number of opioid prescriptions for the same patient at multiple pharmacies
• Additional data may be available from your PBM or health plan, including:
  • Drug therapy class (Generic Product Index (GPI) codes)
  • National Drug Code (NDC) to determine exact strength/dose
  • Days’ supply and quantity dispensed
  • Prescriber and pharmacy NABP information
  • Diagnosis codes (if available)
• Identify patients with poor adherence to non-opioid medication therapy
• Include under and over utilization of opioids and non-opioid therapy
• Be sure to include specialty pharmacy data as well as data from traditional PBM vendors

Keep in mind that some of this information may be available only through a “buy up” program around medication management or fraud, waste and abuse. Different PBMs may have different options in their programs, including what is included in their reporting packages.

Integrating Pharmacy and Medical Data

An assessment of appropriateness of treatment for painful conditions is only possible when both a medical diagnosis and the treatment prescribed are evaluated together. When both are available, consider the following steps in order to make more informed decisions on how to support your covered population:¹

• Identify conditions, such as fibromyalgia and migraines, where opioids may be prescribed in a manner that is not consistent with treatment guidelines.
• Work with your PBM or other vendors to assess quality metrics and potential interventions for quality improvement and enhanced care coordination
• Identify patient populations and conditions that may be undertreated
• Add additional interventions or reviews when prescriptions for naloxone, a reversal agent for opioid overdose, are adjudicated with a chronic opioid. For example:
  • Care coordination for substance abuse treatment; ensure the member receives care by a prescriber certified through Substance Abuse and Mental Health Services Administration (SAMHSA)
• Work with the PBM to incorporate appropriate contract language that addresses the above clinical interventions and outcomes
• Evaluate the overall percent of opioid prescriptions utilized by your population over time and compared to national trends
• Compare opioid prescribing rates for your most common and costly painful conditions to national benchmarks
• Discuss opportunities for intervention with your PBM or health plan when:
  • Opioid prescribing trends are higher than published benchmarks
• A wide variation in opioid prescribing trends is identified by prescriber or prescriber type for a specific painful condition

Prescribing Trends for Pain Management

Because an assessment of clinical appropriateness for a patient’s specific condition is not possible through an aggregate analyses, published prescribing rates serve as a reference when evaluating the prevalence of opioid prescribing for treatment. These prescribing trends serve as a benchmark to determine if further evaluation or prospective interventions are warranted.

Click on the links below to learn about prescribing trends for specific conditions and situations: