Medication Management

Addressing Pain Management & Opioid Use/Abuse

Pain Management & Opioid Abuse Strategies:
Medication Management

The majority of chronic pain is thought to be caused by the following three mechanisms, either separately or in combination:1

  • Nociceptive – damage to the tissues due to trauma or inflammation
  • Neuropathic – damage to the nerve
  • Hypersensitivity to pain

Ideally, pain treatment is targeted to the type of pain a person is experiencing. However, there is often more than one type and some conditions have multiple causes. For example, low back pain can be a result of both neuropathic and nociceptive causes.

In addition to use with chronic conditions, opioids can be appropriate first line agents for nociceptive acute pain caused by trauma, surgery or inflammation. The following table reflects the appropriate treatment by medication class for specific types of pain.

Appropriate Treatment of Pain1

Type of Pain
Nociceptive Neuropathic (Nerve) Pain Hypersensitive
Examples
Arthritis Shingles Fibromyalgia
Treatment
NSAIDS/APAP AED / SNRIs / TCAs AED / SNRIs / TCAs
Role of Opiods
Last Line Last Line Should be avoided

NSAIDS = non-steroidal anti-inflammatory medications
APAP = Acetaminophen
AED = anti-epileptics
SNRIs = serotonin norepinephrine receptor inhibitors
TCAs = Tri-cyclic antidepressants

Work with your PBM and health plan to develop guidelines for pain management including when opioids can be prescribed. It is also very important to identify processes to intervene when abuse is suspected by patients or prescribers. For example:1

Point of Sale (POS)

  • Use concurrent drug utilization review
  • Set a days’ supply limit for short-acting opioids
  • Set a threshold morphine equivalent dose/day (MED)
  • Discuss with your health plan and PBM what the patient will be told, how to assist them if a reject is required and how to determine if more information is needed

Retrospective Drug Utilization Review

This process reviews drug therapy after the patient has received the medication and aims to detect patterns in prescribing, dispensing or administering drugs:1, 31

  • Identify and target prescribers/pharmacies for therapeutic duplication and/or overutilization based on days’ supply, refill thresholds, MED, etc.
  • Identify members exceeding the daily average MED and thresholds for various prescribers and pharmacies; if identified, coordinate pharmacist outreach to prescriber to determine appropriateness of patient’s medication utilization
  • Summarize pain-related medication utilization at the drug class level

For help evaluating your PBM’s ability to manage opioid prescriptions and identify potential abuse, click here for a Prescription Drug Employer Kit from the National Safety Council.