Special Topics in Pain: Opioids

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Reducing Opioid Misuse: Evaluation of a Medicaid Controlled Substance Lock-In Program.

Author(s): Skinner A, et al.
Journal: The Journal of Pain. 2016; 17(11):1150-1155. 26 references.
Reprint: Asheley Cockrell Skinner, PhD, Duke Clinical Research Institute, 2400 Pratt Street, Office B047, Durham, NC 27705. Email: asheley.skinner@duke.edu
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids; Review and evaluate the latest advances and newest information in the area of Economic considerations

Editor's Note: North Carolina Medicaid initiated a "Medicaid Lock-in "program which seems no more than what is prudent practice-have recipients of controlled substance prescriptions fill them in one pharmacy (which must be coupled with a PDMP) to combat fraud and diversion and it seemed to work. Concerns about the program seem hard to fathom.

Class: Opioids, legal

Medicaid Lock-In Programs (MLIPs) are designed to identify Medicaid patients at risk of health-related issues cased by the potential overutilization of controlled substances (CSs) and tightly regulate their access, generally by requiring that patients use a single prescriber and/or pharmacy to obtain certain CS prescriptions for a specified period of time.  

The North Carolina (NC) Recipient Management MLIP was implemented in October 2010 in response to a report that NC was 1 of 5 states with an unusually large number of claims for CS prescriptions.  The NC MLIP was intended to reduce fraudulent prescription claims for opioids and antianxiety CS medications, while improving continuity of treatment among patients with high utilization of CS prescriptions. The NC MLIP might result in significant improvements in care utilization, health outcomes and quality of life.

The data for this study were comprised of NC Medicaid claims provided by the NC Division of Medical Assistance, which manages the State's Medicaid Program. Data were structured to provide total opioid prescriptions according to month for each Medicaid-enrolled individual. Any given individual could have provided up to 57 months of data. Excluded all months before the individuals first month in which Medicaid paid for an opioid prescription they filled. To ensure the study did not capture residual and potentially altered effects related to disenrollment from the MLIP, ll months after an individual was no longer enrolled in the program were excluded.

The final sample included 6,148 NC MLIP enrollees who collectively had 211,666 months of data during the study period.  The mean age of MLIP participants at their time of enrollment was 35 years, and they were predominantly female (69%) and white (78%). Almost two-thirds (64%) of all enrollees' months included at least 1 claim for an opioid. The number of months including at least 1 opioid claim differed markedly before (70%) and after (47%) a participant's enrollment in the MLIP. The mean number of opioid prescription claims (including months with no prescriptions) was 1.62 before enrollment in the MLIP and .84 after enrollment. There were also reductions in the mean number of pharmacies used, mean total days supply received, and mean total units dispensed.

The study found that enrollment in the MLIP resulted in reductions in the average number of opioid prescriptions filled per month and the number of pharmacies visited to obtain those prescriptions. It was found that the odds of having an opioid prescription in any given month while enrolled in the program was 84% lower than before enrollment. Each month, on average, patients received approximately 1 fewer opioid prescription and visited fewer pharmacies to obtain these opioids. As expected, these differences further corresponded with reductions in the total days of supply received (mean difference: -9.6) and the total units dispensed (mean difference: -40.3) each month. Finally, the study showed that the MLIP reduced the program/s drug costs by an average each month of $22.78 per MLIP patient. These findings would appear to provide clear evidence of the program's effectiveness in reducing Medicaid-covered opioid prescriptions, at least in NC.

Concerns have been expressed that restrictions on MLIP participants' access to providers and dispensers--particularly providers--may lead to needless and preventable suffering. There is a need for more research on patients' experiences as enrollees, and particularly the effects of enrollment on their quality of life and their access to CSs in response to legitimate needs.  The guiding principle of primum non nocere applies here as it does to all other aspect of the health care system; particularly because of the relative vulnerability of Medicaid populations.

Important Points:
The misuse and abuse of prescription drugs, particularly opioids, has become a problem at all levels of the health care system. Misuse can result in excessive use of medical services and the cost of these opioid medications often represent one of the largest portions of Medicaid Pharmacy expenditures. MLIPS may constitute a successful component of comprehensive efforts to reduce misuse of opioids and other prescription medications. Care should be taken, however, to ensure that programs, such as MLIPs do not constrain patients’ legitimate needs for analgesic medications. Additional research will also need to examine the extent to which individuals react to the restrictions of MLIPs by obtaining opioids without using Medicaid coverage, or through illicit means.

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