Opioid Misuse: A Health Plan Perspective Marcus Thygeson, MD, MPH SVP, Chief Health Officer Blue Shield of California

2 The burden for our members Chronic non-cancer pain: ~200 deaths per year from opioid overdose 8,417 members on potentially unsafe therapy (> 50 mg morphine equivalent per day) 3,009 members on very unsafe therapy (> 50 mg ME/d and benzo-diazepines or sedative-hypnotics) Commercial BSC members; data from 1Q2014 pharmacy claims.

3 Hold the presses—these new drugs ARE addictive! CompoundRelative Risk hydrocodone1.000 IR oxycodone2.494 * IR fentanyl5.154 * IR hydromorphone5.828 * IR morphine9.976 * IR oxymorphone6.781 * ER oxycodone * ER fentanyl2.846 * methadone * ER morphine5.051 * ER oxymorphone8.010 * * P <.001 Butler, et al. Harm Reduction Journal, 2011, vol. 8: 29

4 If you want to drain the bathtub, you need to turn off the tap

5 BSC actions for non-cancer pain Current: Identifying and referring “addicts” (> 120 mg ME/day, >= 3 MD or pharmacies) Quantity limits and prior auth Under consideration: Much tighter formulary, quantity, and prior auth limits on at least schedule II drugs Enhanced targeted provider interventions (MD, Pharm, Facility) Pain management Centers of Excellence

6 Stop the cultural iatrogenesis From Medical Nemesis: The Limits of Medicine, by Ivan Illich, 1976: “Cultural iatrogenesis….sets in when the medical enterprise saps the will of people to suffer their reality.” It consists of “the paralysis of healthy responses to suffering, impairment, and death.” From “Prescription for Disaster”, by Rachel Aviv, in The New Yorker, May 5, 2014: “Sullivan told me that in poor, rural regions doctors are using opioids to treat a ‘complex mixture of physical and emotional distress….It’s much more convenient for both patient and physician to speak in the language of physical pain, which is less stigmatized than psychological pain.’ He believes that doctors are inappropriately adopting a ‘palliative-care mentality’ to ‘relieve the suffering of people who have had very tough lives.’” (Mark Sullivan is a professor of psychiatry at the University of Washington.)