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© 2018 Optum, Inc. All rights reserved.

Supporting Sustained Recovery for Opioid Use Disorder

RCPA Conference | Hershey, PA October 3, 2018


Agenda

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Scope of the opioid epidemic

Medication-assisted treatment (MAT)• What does MAT involve?

• What are the benefits and effects of MAT?

• How is MAT integrated into a comprehensive treatment plans to support long-term recovery?

Scope of the opioid epidemic


Opioid use disorder (OUD)

1. Retrieved from https://addiction.surgeongeneral.gov/

Addressing the challenges• Stigma around SUD can make people feel

ashamed or afraid to seek the help they need

• It is a chronic, complex disease difficult to treat

• The marketplace offers wide variability in treatment

• Members struggle to find effective evidence-based care

• Individuals are vulnerable to predatory practices

A medical conditionLike all substance use disorders (SUD), OUD is a condition characterized by a pattern of compulsive substance use in spite of the harmful consequences of repeated use.

Does not discriminateaffects individuals of all ages, gender, race, social and economic status

“A chronic brain disease; not a character flaw or moral failing” Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health. 2016.

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Early exposure and dependence

1. Reinberg, S. (2017). Opioid Dependence Can Start in Just a Few Days. Retrieved from https://consumer.healthday.com/bone-and-joint-information-4/opioids-990/opioid-dependence-can-start-in-just-a-few-days-720750.html. 2. Muhuri, P. (2013). CBHSQ Data Review: Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. Retrieved from https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm . 3. Anuj Shah, A., Hayes, C., Martin, B., Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66. Retrieved from https://stacks.cdc.gov/view/cdc/44655..

Opioid dependence can start in just a few days.1

Risk of chronic opioid use increases with each additional day of opioid supplied starting with the third day.3

80% of heroin usersreport starting on prescription opioids prior to transitioning to heroin.2

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Death due to opioid overdose

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25,000

20,000

15,000

10,000

’00 ’14’12’10‘08’06’04’02

5,000

Heroin and fentanyl Both Common prescription opioids

Deaths due to illicit opioids up 134% from 2012 to 2015.1

National per capita opioid prescribing rates decreased 13.1% from 2012 to 2015.2

1. National Center for Health Statistics, Centers for Disease Control and Prevention . 2. Guy GP Jr., Zhang K, Bohm MK, et al. Vital Signs: Changes in Opioid Prescribing in the United States, 2006–2015. MMWR. Morbidity and Mortality Weekly Report 2017;66:697–704. Retrieved from https://www.cdc.gov/mmwr/volumes/66/wr/mm6626a4.htm


Prescription opioid use by age and gender

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15%

30%

20%

12%

4%

13%

5%

19%

33%

16%

9%

3%

12%

6%

60+

50-59

40-49

30-39

26-29

18-25

13-17

<13

Opioid prescribing by age1

16%

17%

21%

8%

37%

1%

9%

14%

23%

11%

41%

1%

50-59

40-49

30-39

26-29

18-25

13-17

<12

Patients in opioid treatment by age and gender2

1. UnitedHealthcare large ASO employer 2017 claims experience. 2. UnitedHealthcare ASO covered lives 2016, served by Optum Behavioral Health.

MaleFemale


CDC Guidelines for opioid prescribing

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Opioids are not first-line therapy for chronic painNon-opioid and non-pharmacologic treatments are preferred

Short duration for acute pain3 days of therapy should be sufficient, longer than 7 days rarely needed

Avoid opioids in combination with benzodiazepinesAvoid these drugs in combination because of increased overdose risk

Offer MAT for OUDMAT has proven the most effective treatment for OUD

Lowest effective dose at startLess than 50 morphine equivalent dosing (MED) per day at treatment initiation

Minimize dose escalationAvoid increasing dosage to ≥ 90 MED per day

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When people try chiropractic care or physical therapy for back pain first,

1. Optum analytics based on UHC commercially insured population, 2017.

Prevention

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Chronic back pain management

60% lesslikely to use opioids1

patients are


Minimizing early exposure

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Max of 49 MED per day and max 7-day supply on all new short-acting opioid scripts

Limit of two 7-day supply fills within a 60-day time frame

Narrowed refill window (75% to 90% used) on all opioid prescriptions to limit early refills and stockpiling

Prior authorization on all first-fill for a long-acting opioid and opioid-based cough preparations in pediatrics

Alignment with CDC guidelinesAggressive “first-fill” morphine-equivalent dose (MED) and days supply edits


Optum experience

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Pharmacy edits for short-acting prescription opiates

“First-fill” opioid scripts < 50 MED per day

94.7%compliance

“First-fill” opioid scripts < 50 MED per day

94.7%compliance

“First-fill” opioid scripts ≤ 7-days supply

95.2%compliance

“First-fill” opioid scripts ≤ 7-days supply

95.2%compliance

Opioid prescriptions dosed < 90 MED among

current chronic users

96.0%compliance

Opioid prescriptions dosed < 90 MED among

current chronic users

96.0%compliance

On average, 45% of “first-fill” scripts nationally are not in compliance with CDC guidelines1

Compliance with CDC guidelines

29.9%improvement29.9%

improvement13.5%

improvement13.5%

improvement4.5%

improvement4.5%

improvement

1. Note: Results are based on June 2017 vs December 2017 client data and short-acting opioid script volume and do not represent a guarantee of results.

Medication-assisted treatment (MAT)


Substance use disorders are viewed as a chronic disease

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Relapse is a common part of any chronic disease

SUD treatment is similar to medical interventions (e.g., the choice between surgery or medication)• Member’s previous clinical experiences,

individual psychosocial variables, effective treatment choices and outcomes

Chronic illness is best managed in the individual’s local community to aide the development of readily available local recovery supports

Direct correlation between treatment engagement and best outcomes• Treatment provided must be “person-centric” and individualized• Primary goal is to move from acute intervention to long-term

recovery• Acute treatment planning is based on an individual’s current

presentation, past substance use treatment, medical, psychiatric, and social history

• Long-term recovery is focused on each person’s strengths, challenges and barriers to treatment, and continuity of care

No correlation between the intensity of the treatment setting (i.e., inpatient, residential) and treatment engagement and outcomes


Benefits of MAT

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1. Calculated by Optum, based on relative risk ratios from the meta-analysis in: Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD011117. DOI: 10.1002/14651858.CD011117.pub2, pages 17 and 19.

Minimize withdrawal symptoms

Reduce opioid cravings

Prevent relapse

Restore normal physiological functioning

1

2

3

4

50%greater than detoxification or

psychosocial treatment alone.1

Chance of remission (no opioid misuse)


MAT plays a critical role for those with OUD

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It is the standard of care for treatment of OUD1

MAT uses FDA-approved medications with counseling and behavioral therapies to treat substance use disorders and prevent opioid overdose.2

1. National Drug Control Strategy: FY 2016 Budget and Performance Summary, p.7. 2. SAMHSA, Medication Assisted Treatment: Medication and Counseling Treatment. Retrieved from http://www.samhsa.gov/medication-assisted-treatment/treatment.

MethadoneBuprenorphineNaltrexone


MAT works on opioid receptors

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Three medications and three mechanisms of action:

Methadone: an opioid receptor AGONIST

• Fully activate opiate receptors

• Overdose shuts down the respiratory center and causes death

• Other agonists: heroin, morphine and oxycodone

Naltrexone: an opioid receptor ANTAGONIST

• Block and prevent activation of opiate receptors

• No overdose potential

• Cause immediate withdrawals if opioids are in the system

Buprenorphine: an opioid receptor PARTIAL AGONIST

• Partially activate opiate receptors

• Built in “ceiling effect” prevents overdose by themselves

• Cause immediate withdrawals if opioids are in the system


Agonist therapy

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Only provided by federally-regulated clinics• Synthetic, long-acting, full opioid agonist

• Chemically unlike morphine or heroin but acts on the same opioid receptors

Narcotic blockade by cross-tolerance• Eliminates symptoms of withdrawal

• Diminishes experience of “opiate euphoria”

• Reduces “drug hunger” or cravings

• Blocks “reinforcing intoxication”

Mt Sinai J Med. 2001 Jan;68(1):62-74

METHADONE

Benefits of maintenance• Ability to focus on activities of daily living

• Improvement in productive behaviors

– Employment, education, care-giving

– Marked drop in criminal activity and arrests

• Normalization of death rates compared to general public


Replacement therapy

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METHADONE

Induction

• Typical first dose is 20 mg to 30 mg (FDA methadone induction max is 40 mg)

• Steady state achieved within 10 days

Maintenance

• Typical dose is 60–120 mg/day

• Protracted side effects: sweating, constipation, weight gain, pregnancy

Discontinuation

• Slow taper: 10 mg/month until 30–40 mg/day, then 2–5 mg/month

• Conversion to buprenor-phine: 20–30 mg methadone and then stop for 72 hours

• Protracted withdrawals: malaise, depression, anxiety, insomnia, pain, cravings

Outcomes

• Maintenance: 50–80% 1-year retention rate– Discontinuation: 20–30%

abstinence after three years – Most relapse in first month– 59% used heroin over

the 2-year follow-up

• Greater criminal activity and incarceration rates

• Poor outcomes with co-morbid alcohol dependence and substance abuse

Mt Sinai J Med. 2001 Jan;68(1):62-74


Partial agonist therapy

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Brand products:* Suboxone® | Zubsolv® | Bunavail®

Regulated by the DEA (Drug Enforcement Agency)• Require special DEA prescribing license (DATA 2000)

• Eliminates the addictive, reinforcing and euphoric characteristics of a full agonist

Ambulatory and outpatient settingsThree stages of treatment: 1. Induction2. Stabilization3. Maintenance

Treatment considerations• Absence of opiates in the system

• Avoidance of sedative use

• Can be used at all levels of care

• Can be used while treating psychiatric and medical comorbidities

• Can be used with MAT for nicotine use disorder

• Cannot be used simultaneously with naltrexone or methadone

*Contains small amount of naloxone | **Except naltrexone

BUPRENORPHINE


Stages of treatment

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BUPRENORPHINE

Intake

• Establish suitability for treatment

• Discuss substance use history

• Assess readiness for change

• Confirm support systems/networks

• Review treatment plan/expectations

• Sign patient contract

Induction

Day 1• Member in moderate

withdrawal• Initiate induction• Additional medications

as needed

Day 2• Re-evaluate• Discuss side effects,

adjust dosage • Prescription only to last until

next visit• Review ongoing counseling

and sober support use

Stabilization

• Continue to assess withdrawal symptoms

• Member begins stable daily dose

• Begin counseling, group therapy and sober supports

• Relapse prevention and planning

• Weekly follow-up and drug screening

• Prescription only to last until next visit

Maintenance

• Continue stable daily dosage

• Decrease visit frequency

• Continue UDS with prescriptions

Taper

• Long taper: more than 30 days

• Moderate taper:14 to 30 days

• Rapid taper:3 to 5 days


Opioid “detox”: Facts and fictions

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Opiate withdraw symptoms

• Symptoms of opioid withdrawal are not life-threatening

• Clinical management does not require 24-hour nursing care

• Untreated withdrawal symptoms often result in continued use

Opioid withdrawal management

• Detox only is not considered treatment for OUD

• Detox only does not decrease the incidence of relapse

• Detox only does not increase community sobriety or tenure

• Detox only does increase the risk for unintentional overdose


“Detox”

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Rapid induction-reduction with buprenorphine

BUPRENORPHINE

Induction phase

• 1 to 2 days

• Typically seen in inpatient detox or enhanced programming

Reduction phase

• Rapid reduction: 3 to 5 days– “Detox” has no compelling reason– More likely to overdose upon relapse– Has not considered treatment

• Moderate reduction: 14 to 30 days– No compelling reason for short-term

reduction– Unwilling or unable to engage in

treatment with ongoing treatment

• Long reduction: 30 days or longer– Compelling reason to engage in

rehabilitation– Unwilling or unable to engage in on-

going therapy

Post-taper phase

• Indefinite period

• Continue individual therapy, group therapy, sober supports

• Address medical, behavioral and social problems


Antagonist therapy

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• Used to prevent relapse or diminish the effect of opioid use

• Naltrexone causes withdrawal symptoms if an opiate is in the system – Oral challenge for 5–7 days followed

by intramuscular injection

– Oral challenge for 5–14 days after detox or methadone conversion

NALTREXONE

Two dosing schedules for oral Naltrexone• 50 mg/day; can increase to 100 mg/day if needed

• 100 mg M–W–F +150 mg over the weekend

One dosing schedule for injectable naltrexone• Given as a 380 mg intramuscular injection dose

every four weeks

• Special pharmacy order; not self-administered

• Vivitrol®: brand name of long acting formulation


MAT considerations for special populations

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Pregnant women• MAT for maintenance is preferred over MAT for withdrawals

– Either methadone or buprenorphine can be prescribed; however, if a pregnant patient is stable on methadone do not change to buprenorphine

– Infants born to women who received buprenorphine during pregnancy 1) developed milder neonatal opioid withdrawal symptoms (NAS) than those born to women who received methadone, and 2) needed fewer post-delivery hospital days

– MAT should begin immediately when a pregnant opiate addict presents for treatment; MAT should be continued through the pregnancy

– If a patient is using buprenorphine, the drug should be used alone (without naloxone)

• Breastfeeding is encouraged on both medications

Adolescents• All treatment options are to be considered

– Some MAT are not FDA-approved for adolescents – Clinical reasoning for not providing MAT should always be documented

BUPRENORPHINE


What our experience shows

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1. Based on Healthcare Analytics review from 11-1-2014 to 10-31-2015 claims data for Optum Commercial Business; there were 10,373 members who were admitted to a facility-based level of care with an opiate-based primary diagnosis.2. McLellan AT1, Arndt IO, Metzger DS, Woody GE, O’Brien CP. The effects of psychosocial services in substance abuse treatment. JAMA. 1993 Apr 21;269(15):1953-9.


Dispelling a myth about MAT

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Many objections to MAT are based on the belief that it replaces one dangerous drug with another

SUDs are characterized by harmful consequences of repeated useDSM-5 criteria for diagnosis: Maladaptive Pattern of Substance Use • Leading to clinically significant impairment

or distress over 12 months• Note: Withdrawal and tolerance symptoms by

themselves do not denote a substance use disorder

Most people using MAT are quite functional again and are able to fulfill their responsibilities

a treatmentMAT is


MAT need significantly exceeds capacity1

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Physicians are not prescribing.

1. August 2015, Vol 105, No. 8, American Journal of Public Health. 2. Vestal, C. In Drug Epidemic, Resistance to Medication Costs Lives,” The PEW Charitable Trusts. January 11, 2016. 3. Knudsen HK, Roman PM, Oser CB. Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations. Journal of Addiction Medicine 2010;4(2):99–107. 4. Knudsen HK,, Abraham AJ, Roman PM. Adoption and Implementation of Medications in Addiction Treatment Programs. Journal of Addiction Medicine 2011 5(1): 21–27.

Only 3.5% of 900,000 U.S. physicians who can write prescriptions for opioid painkillers have obtained a DATA 2000 waiver to prescribe buprenorphine ― and only a fraction of those licensed actually prescribe it.2

Only 23% of public and less than 50% of private-sector treatment programs offer any FDA-approved medications to treat SUD/OUD.3,4

Even in programs that do offer MAT, only 34.4% of patients receive it.4


Importance of community tenure

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Treatment in an individual’s home community improves the chance of sustained recovery Allows people to create a readily accessible support system (primary care providers, mental health professionals, friends, family, peers, and community sober supports).

ASAM treatment guidelines suggesting that psychosocial treatment in conjunction with MAT “should include ... links to existing family supports and referrals to community services.”


The rising trend of destination treatment

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A cottage industry has formed to influence consumers to choose high-cost, ineffective treatment centers• Most consumers are not aware of what treatment options exist.• Stigma causes many to seek anonymous help.• Call centers advertise aggressively (online, late-night television, billboards) to connect

with consumers when they are ready to engage.• Destination centers buy these leads and charge exorbitant fees for inadequate care.

1. Optum comparative analysis of average annual readmission rates for in-network and out-of-network residential SUD treatment programs authorized for members from January to December 2017. Data includes membership in all age cohorts from the commercial book of business. Bolstrom, May 2018 2. Comparison of average 90-day episode-of-care cost for out-of-network residential treatment ($42212) to that for in-network residential treatment ($10440-$15291); “Episode of Care” is defined as claims between three days prior to admission through 90 days after discharge; Bolstrom, May 2018 3. Increase in claims for four common lab test CPT codes for substance use; Source: FAIR Health Study: The Impact of the Opioid Crisis on the Healthcare System: A Study of Privately Billed Services, September 2016.

105%–142% higher30- and 90-day readmission rates per year1

304% higher cost for 90-day episodes of care2

Over 1,000%increase in lab testing utilization from 2011–143


The ER as a first step to long-term treatment

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“The emergency department is a health care setting in which patients with opioid use disorders commonly present …

Emergency physicians are thus uniquely positioned to intervene to help patients with opioid use disorders at a critical moment in the addiction cycle.”

— David Kan, CSAM

SEE NOTES: This is one area where the ER, health plans and community providers can work together to have an effective intervention with follow-up arranged before discharge

Supporting long-term recovery


Support long-term recovery

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Help individuals avoid relapse Support chronic populations and recovery1. Connect individuals with certified peer support

specialists– Uniquely qualified support resources that have made the journey

from substance abuse to recovery themselves

2. Equip individuals with recovery tools– Mobile apps offer guidance, reminders and immediate

help when needed

3. Continuously monitor pharmacy claims data – Inform doctors and pharmacists how to reach out to individuals

who may need extra support to avoid relapse– Drug Utilization Review (DUR): concomitant use of opioids and

MAT

1. National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. Accessed July 2017; 2. Ann Intern Med. 2016; 164:1-9; 3. Psychiatric Serv in Advance. 2016

40–60%average relapse rate amongst opioid abusers in the U.S.1

91%of patients who overdose receive an opioid prescription within 10 months.2


1Results from an Optum January 2017 analysis of 338 members who enrolled in Optum peer support services between February 1, 2014 and February 28, 2016; results are within six months after enrollment compared to six months prior to enrollment; participants had continuous eligibility for six months pre- and post-referral and at least one behavioral health (mental health and/or substance use) claim during that period; Source: Ten Eyck, 11/06/2017.

Reduction in inpatient days124%

Long-term recovery: Peer support

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Offer personalized assistance through certified peer support specialists

Engagement with peers is important in all stages of treatment and recovery

Reduction in overall behavioral health costs1

21%• Engage individuals to design recovery

plans based on strengths and goals• Coordinate with the care system

to ensure adherence• Demonstrate they are successful

in their own recovery

Discussion

Jeffrey MeyerhoffSenior Medical Director, Optum Behavioral HealthEmail: [email protected]: (763) 283-3114

Thank you. Contact information:

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