A Program to Identify Opioid-Dependent Health Plan Members

Cincinnati—According to an article in Drug and Alcohol Dependence, the risk for death for patients who are dependent on opioids is 5.71 times greater than for healthy individuals of similar age, sex, and race.

In June 2012, Aetna Pharmacy Management launched a program aimed at monitoring use of the opioid Suboxone^® (buprenorphine and naloxone) to enhance patient safety. The program was designed to reduce prescription drug misuse and abuse while helping to ensure safe and appropriate use of Suboxone.

The program notified Suboxone prescribers by letter of overlapping claims for Suboxone and opioid and/or tramadol pharmacy claims from Aetna members. A retrospective programming application runs on weekdays to identify fully insured commercial members who have pharmacy claims for Suboxone and concurrent pharmacy claims for opioid and/or tramadol.

When the overlap is identified, the system generates and mails a letter to the Suboxone prescriber. The letter is followed within 2 weeks by an outbound telephone call from a pharmacist to the prescriber to ensure receipt of the letter and provide additional information, if needed. The prescriber is encouraged to discuss the opioid/tramadol fill with the member.

Effective May 1, 2012, if ongoing opioid/tramadol use is identified as misuse or abuse, Aetna will deny future coverage for opioid/tramadol pharmacy claims.

The program generated letters to Suboxone prescribers for 2455 members (1456 male and 999 female). Members 30 to 34 years of age had the highest number of letters sent. The state with the highest member percentage receiving letters was Florida (16.3%), followed by California (14.3%), Texas (10.7%), Pennsylvania (9.8%), and New Jersey (9.3%). The program identified members belonging to 1664 unique plan sponsors.

Members stopping opioid/tramadol use within the postanalysis period of 4 months defined program success. The date the letter is mailed plus 15 days is the start date; the end date is the last day of the fourth month after the letter is mailed, or when the next letter is mailed, whichever comes first.

Aetna reported that 1491 members were successful in stopping opioid/tramadol use within the postanalysis period. The successful member population was 58% male and 42% female. Overall, following the mailing of the letters and telephone calls completed, 60% males and 63% females stopped opioid/tramadol use within the postanalysis period.

Even though more letters were sent to, and telephone calls were completed with, males compared with females, the overall success rate was higher for females than for males. From June 2012 through July 2012, the overall success rate of the program for both males and females was 61%.

The poster noted “identifying sex, age, residence, and plan sponsor will assist with targeting behavioral health and educational programming to help the opioid-dependent member population.”

This research was conducted by Aetna Inc., with no external funding.