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February 2016 Clinical Knowledge Management News for Clients Controlled Substance Strategies at CVS Health This Issue in Brief Controlled Substances ...............1 Opioid Medication Uses and Risks ..................2 Cost of Opioid Abuse........................2 Overprescribing of Controlled Substances ...............2 Risk Factors for Adverse Outcomes in Opioid Abuse........................3 Guidelines for Opioid Management .............3 CVS Health Controlled Substance Management Programs .............. 4-6 Questions and Answers for Clients..................7 Introduction Many controlled substances have a useful and legitimate medical purpose, such as for treatment of pain.1,2 However, controlled substances have a potential for abuse and have been associated with overdose deaths, emergency room visits and other adverse health consequences.2,3 Overprescribing is a contributing factor—for instance, overprescribing of opioids is associated with higher rates of drug overdose deaths and substance abuse treatment admissions.4 Addressing prescribing practices is one strategy that has been recommended to help reduce these problems.5 We recognize that patients need to receive the appropriate controlled substances to treat their conditions, and the benefits and risks associated with these treatments must be carefully considered. To this goal, we offer programs to help ensure safe and clinically appropriate controlled substance medication therapy for plan members and retail customers, and to help produce cost savings for clients through more clinically appropriate medication regimens. This client briefing will discuss information about controlled substances, with a focus on opioid pain medications; issues with overprescribing; and our controlled substance strategies. Controlled Substances The term “controlled substance” refers to a drug or other substance, or immediate precursor (certain chemicals used to make drugs), that has been assigned to one of five categories, called “schedules,” which are established by the Controlled Substances Act.2,6 Each drug’s assignment is based on its potential risk of abuse and acceptable medical use.2,6 Abuse of prescription drugs, also called “nonmedical use,” is defined by the National Institute on Drug Abuse as “the use of a medication without a prescription, in a way other than as prescribed, or for the experience or feelings elicited.”7 Schedule I substances have the highest potential for abuse and are considered the most dangerous.6 As the drug schedule changes from Schedule II, Schedule III, etc., so does the abuse potential—Schedule V drugs represent the least potential for abuse.6 Some types of controlled substances are opioid analgesics, benzodiazepines and stimulants.8 The Drug Enforcement Administration (DEA) ranks controlled prescription drugs as one of the most significant drug threats to the United States because the number of deaths attributable to controlled prescription drugs has outpaced those for cocaine and heroin combined, and opioid use can lead to heroin use for some.9 The amount of opioids for abuse available on the prescribed market is significant, and more than 80 percent are oxycodone and hydrocodone products.9 The comments contained herein are the opinion of CVS Caremark Medical Affairs. This document contains proprietary information of CVS Health and cannot be reproduced, distributed or printed without written permission from CVS Health. Saving projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. ©2016 CVS Health. All rights reserved. 106-36743A 022216 February 2016 Clinical Knowledge Management News for Clients Opioid Medication Uses and Risksa Prescription opioid medications are used to treat severe acute pain, such as from surgery or injury, and chronic pain from active cancer or at the end of life.1,10 Guidelines from the American Pain Society (APS) and American Academy of Pain Medicine (AAPM) state that chronic opioid therapy can also be an effective therapy for carefully selected and monitored patients with chronic noncancer pain.1 Some medications in this class include hydrocodone, oxycodone, morphine, methadone, buprenorphine and codeine.11-13 However, opioid medications are associated with dependence, tolerance, abuse and risk of accidental overdose.14 One study found that death rates for drug overdoses involving opioids were 7.8 per 100,000 adults aged 18 through 64 years in 2013, an increase from 4.5 per 100,000 in 2003.15 The same study, which looked at nonmedical prescription opioid use and use disorders, also found increases in the prevalence of opioid use disorders and frequency of use during the same period, although the prevalence of nonmedical use of prescription opioids decreased.15 Opioids can also have side effects, such as sleepiness and constipation.16 They can worsen pain, impair driving, and affect the immune system, and they are associated with a number of drug interactions.16 Cost of Opioid Abuse The cost of opioid abuse is estimated to be about $53 billion to $56 billion annually, accounting for medical and substance abuse treatment costs, lost work productivity and criminal justice costs.17,18 According to a study that examined the costs of opioid abuse from the employer perspective, those who abused opioids had higher average annual per-patient health care costs than their matched comparison patients—$20,343 versus $9,716, respectively, yielding excess costs of $10,627 (health care costs were inflated to 2012 U.S. dollars).19 The study also found that people who abused opioids had $1,244 in excess annual per-patient indirect work-loss costs over matched comparison patients (average costs $3,773 versus $2,528, respectively).19 Based on these costs, the authors estimated that the employer burden for diagnosed abuse was $1.71 per member per month (PMPM).19 Overprescribing of Controlled Substances Overprescribing of controlled substances, such as opioids, is an area of concern. Health care providers wrote 258.9 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of these pills.4,20 While those in the United States constitute only 4.6 percent of the world’s population, they consume 80 percent of the global opioid supply and 99 percent of the global hydrocodone supply.21 According to the Centers for Disease Control and Prevention (CDC), overprescribing of opioids is associated with higher rates of drug overdose deaths and substance abuse treatment admissions.4 In 2014, 6.5 million people aged 12 years or older reported nonmedical use of psychotherapeutic drugs—about two-thirds of those people were taking pain relievers nonmedically.22 National Survey on Drug Use and Health data indicate that 53 percent of nonmedical users of controlled prescription drugs (pain relievers, tranquilizers, stimulants and sedatives) aged 12 or older obtained the prescription drugs they most recently used “from a friend or relative for free,” and 21.2 percent reported obtaining them from “one doctor,” according to a recent report from the DEA.9 More than four in five of those who obtained prescription drugs from a friend or relative for free reported that their friend or relative had obtained the drugs from a single doctor.9 Strategies to address overprescribing are essential. For instance, the U.S. Department of Health and Human Services recommended looking at opioid prescribing practices to reduce opioid use disorders and overdose as one of the three priority areas they identified in an initiative to combat opioid abuse.5 a ® All opioids are not indicated or approved for use in all clinical situations. For example, transmucosal immediate-release fentanyl products (e.g., Actiq ) are FDA-approved and indicated in nationally recognized compendia only for the management of breakthrough pain in cancer patients who are already receiving and who are tolerant to around-the-clock opioid therapy for their underlying persistent cancer pain. References: Actiq [package insert], Frazer, ® PA, Cephalon, Inc., December 2011; Micromedex Solutions, http://www.micromedexsolutions.com, Accessed February 10, 2016. The comments contained herein are the opinion of CVS Caremark Medical Affairs. This document contains proprietary information of CVS Health and cannot be reproduced, distributed or printed without written permission from CVS Health. Saving projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. ©2016 CVS Health. All rights reserved. 106-36743A 022216 February 2016 Clinical Knowledge Management News for Clients Risk Factors for Adverse Outcomes in Opioid Abuse A number of risk factors have been associated with adverse outcomes in opioid use, such as overdose and progression to substance abuse.23-25 We can pursue improved clinical outcomes through positively impacting the following measures of controlled substance use: • Morphine equivalent dose (MED) greater than 120 mg/day, although risk also exists at lower doses.24,25 Determining MED is the process of converting from one opioid agent to an equivalent dose of another agent or changing the route of opioid administration using morphine as the reference standard.26 It is used for determining the dose when a patient is on one or more opioids25 • Use of opioids for greater than 90 days24 • Multiple prescribers and pharmacies23 • Combinations of central nervous system depressants (such as benzodiazepines and other sedatives—hypnotics, antidepressants and sleep aids—along with an opioid)23 Guidelines for Opioid Management Improving the way opioids are prescribed through clinical practice guidelines can help to ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse or overdose from these drugs.20 CVS Health continuously reviews guidelines to help ensure CVS Health controlled substance programs are consistent with current treatment recommendations. Eight guidelines were reviewed by the CDC National Center for Injury Prevention and Control, the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of the National Coordinator for Health Information Technology (ONC) to identify common recommendations.27 These guidelines were issued on or before January 2013 and were developed by professional societies, states or federal agencies for general practitioners.27 Common recommendations found in all the guidelines included27: • Conducting a physical exam, pain history, past medical history and family/social history • Conducting urine drug testing, when appropriate • Considering all treatment options, weighing benefits and risks of opioid therapy, and using opioids when alternative treatments are ineffective • Starting patients on the lowest effective dose • Implementing pain treatment agreements • Monitoring pain and treatment progress with documentation; using greater vigilance at high doses • Using safe and effective methods for discontinuing opioids (e.g., tapering, making appropriate referrals to medicationassisted treatment, substance use specialists or other services) Our Opioid Prescriber Toolkit, which is available to all Enhanced Safety/Monitoring Solutions (ESMS) clients, is used to educate and assist physicians in providing appropriate therapy to patients with chronic noncancer pain. It is based on CDC, SAMHSA and ONC guidelines, as well as guideline recommendations from the following authoritative organizations—the APS/AAPM Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain, and the American Society of Interventional Pain Physicians Guidelines for Responsible Opioid Prescribing in Chronic Non1,27,28 Cancer Pain. The comments contained herein are the opinion of CVS Caremark Medical Affairs. This document contains proprietary information of CVS Health and cannot be reproduced, distributed or printed without written permission from CVS Health. Saving projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. ©2016 CVS Health. All rights reserved. 106-36743A 022216 February 2016 Clinical Knowledge Management News for Clients CVS Health Controlled Substance Management Programs At CVS Health, opioid analgesics is one of the top classes driving trend—it was the twelfth leading class contributing to 2014 trend. Oxycodone/acetaminophen, buprenorphine/naloxone, and hydrocodone/acetaminophen were the leading drugs in this class, totaling 0.18 percent contribution overall. We offer a number of programs that address management of controlled substances across CVS Caremark® and CVS Pharmacy®—prospective controls, retrospective controls, prescriber management, and retail programs, which include community programs. Prospective controls refer to those conducted prior to a prescription, service, or course of treatment, while retrospective controls refer to those conducted after prescription services have been provided to the patient.29 CVS Caremark Controlled Substance Programs Prospective Controls • Mail Pharmacy Review. At our mail order facilities, a group of pharmacists review prescriptions for Schedule II opioid pain management medications to determine if they are legitimate and should be filled. These pharmacists evaluate each prescription following our pain management protocol for appropriateness of therapy. Edits form on prescriptions if certain criteria are met, such as an excessive number of fills, prescribers, or pharmacies, or if a patient is receiving combination therapy that increases the risk of overdose, such as an opioid, carisoprodol, and a benzodiazepine. These edits are reviewed by the pharmacists. Our mail order pharmacies also validate that prescribers’ DEA numbers are valid and that they are not prescribing for themselves or their immediate family. Prescribers with prescribing habits that may be questionable and/or raise red flags (e.g., same diagnosis for all patients, same medications prescribed for all patients) are researched and presented to our Prescriber Review Panel to decide if any action should be taken. Prior to making the decision to block a prescriber, we will contact the prescriber to address our concerns. If a prescriber is blocked, no controlled substance prescriptions written by this prescriber will be filled at our mail or retail pharmacies. • The Utilization Management (UM) team creates programs and tools that are designed to encourage safe and effective drug utilization, help enhance plan members’ health outcomes and promote cost-effective drug benefit plan designs for our clients that subcontract/delegate these services. Programs and tools are based on the latest FDA-approved product labeling, authoritative drug compendia, journals, nationally accepted practice guidelines and government agency guidance. They are reviewed internally and by external consultants (specialists in their fields) to help ensure clinical integrity and compliance with regulatory agency standards. UM programs related to controlled substances are prior authorization (PA) and quantity limits (QL). o With PA, restrictions are based on clinical criteria, such as diagnosis, evaluation and step therapy o With QL, criteria such as maximum daily dosing per labeling, initial dosing frequency recommendations or dose in opioid-tolerant patients are used • Point of Service (POS) Drug Utilization Review (DUR) is a frontline safety review to prevent medication issues at the point of dispensing (retail and mail). Our POS Safety Review utilizes a series of edits designed to check members’ prescription history for possible drug conflicts and safety issues. A few of the many edits are drug-drug interaction, drug-age alert and high-dose alert. Edits specifically addressing controlled substance issues may include cumulative acetaminophen (cAPAP), cumulative morphine equivalent dose (cMED), multiple prescribers, multiple pharmacies and excessive controlled substances. The comments contained herein are the opinion of CVS Caremark Medical Affairs. This document contains proprietary information of CVS Health and cannot be reproduced, distributed or printed without written permission from CVS Health. Saving projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. ©2016 CVS Health. All rights reserved. 106-36743A 022216 February 2016 Clinical Knowledge Management News for Clients Retrospective Controls • Safety/Monitoring Solutions (SMS) identifies members who may potentially be misusing or overusing controlled substance medications, and notifies involved prescribers about members’ controlled substance drug utilization patterns. In SMS, member prescription claims histories are reviewed and screened for parameters such as the number of controlled substance prescriptions, the number of physicians and the number of pharmacies a member is using. After potential high-risk members are identified, pharmacists perform clinical reviews of the medication profiles to determine if they are consistent with nationally recognized guidelines or if an intervention—a letter mailed to the prescriber requesting review of the therapy—should be made. • Enhanced Safety/Monitoring Solutions (ESMS) is considered the next step for cases not resolved by SMS for clients that have implemented ESMS. Most cases referred to ESMS come from the core SMS program, but referrals can come from other sources such as the client, the customer care area or the account team. Cases are reviewed and investigated thoroughly, with more individual attention given and background research done on the member, prescriber and pharmacy than in the SMS program. The ESMS team recommends to the client a variety of actions depending on the situation, which include advanced lettering to prescribers, pharmacies and members; pharmacy lock-ins and audits; prescriber follow-up; opioid prescriber toolkit; independent physician consultation; medication therapy counseling; and special investigations referral. • Fraud, Waste and Abuse (FWA) Program. The FWA team reviews quarterly claims reports to identify high utilizers of controlled substances, high-volume prescribers, and potential cases of FWA, such as inappropriate billing, doctor shopping, and providing false information. Investigation and resolution can involve internal processes or working with state and federal law enforcement. • CVS Caremark Retrospective Solutions is a retrospective review of patients’ prescription claims histories. The review targets specific risk factors and at-risk member populations, for example elderly or high-risk users. Drug safety reviews involve monitoring controlled substance prescription claims (e.g., pentazocine, meperidine, testosterone therapy, barbiturates, muscle relaxants and benzodiazepines) for irregular use, which includes: − Multiple prescribers of narcotics, − Multiple prescriptions for the same controlled substance, − Excessive dosages, or − Drug-drug interactions. Additionally, pregnant women on chronic opioids who are at risk for neonatal abstinence syndrome are identified. Interventions are made by contacting prescribers. Prescriber Management • Retail-PBM Collaboration for Physician Overprescribing. Prescribing trends that indicate irregular prescribing behavior are reviewed, and prescribers who warrant deeper review are discussed by a Prescriber Review Panel composed of clinicians. We may refuse to fill prescriptions written by identified prescribers at both our retail and mail pharmacies. The comments contained herein are the opinion of CVS Caremark Medical Affairs. This document contains proprietary information of CVS Health and cannot be reproduced, distributed or printed without written permission from CVS Health. Saving projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. ©2016 CVS Health. All rights reserved. 106-36743A 022216 February 2016 Clinical Knowledge Management News for Clients CVS Health Retail Programs At CVS Pharmacies Pharmacists have a legal responsibility to ensure all prescriptions dispensed have been written for a legitimate medical purpose by prescribers practicing within the scope of their practice. Each year, we provide detailed training to all pharmacists and support staff on how to recognize and address prescriptions of concern to help prevent the diversion of these opioids into our communities. Specific training is provided to retail pharmacy pharmacists and support staff centered on identifying areas of concern, such as “red flags,” when dispensing controlled substances. Red flags can be concerns with the therapy/dosing, the prescription, the patient or the prescriber. To ensure an opioid prescription has been written for a legitimate medical purpose, the retail pharmacy may consult with the prescriber to validate dosage and obtain diagnosis code, review the patient’s profile for therapy duplication and cadence of fills, and check the state’s Prescription Monitoring Program (where available) to understand whether the patient is visiting multiple doctors and/or pharmacies. We conduct a regular review of high-risk prescribing patterns observed within prescription data. In certain instances where concerning outlier patterns are observed, we conduct outreach to prescribers to resolve these concerns and promote safer prescribing practices. Additionally, from an aggregate level, all CVS Pharmacy dispensing is assessed on a regular schedule as part of a formalized process to understand controlled substance dispensing. Any pharmacy identified with specific opioiddispensing characteristics requiring follow-up enters into a review and education program. CVS Pharmacy Outreach to Communities We recognize the importance of removing unwanted, unused, or expired medications from our communities in a safe and environmentally responsible manner. Through our Medication Disposal for Safer Communities Program, we have demonstrated our commitment to the safe disposal of this unwanted medication to help prevent prescription drug abuse and diversion. Our Safer Communities Program has donated more than 420 medication collection units to law enforcement departments across the country as a way to help them start a medication collection program. We raise awareness in our communities about these sites, as well as other drop-box locations, that are available year round for customers to dispose of their unwanted prescription medication. Currently we have more than 1,000 CVS Pharmacy locations displaying in-store signage to direct our customers to these take-back locations. The units that we have donated have helped facilitate the removal of more than 43,000 pounds of medications—close to 20 metric tons over the life of the program. This is the sum total for all collections starting when the units were beginning to be delivered in September 2014 through the end of Q3 2015. We have a standing offer to law enforcement to use our pharmacy parking lots to host a take-back event, including the National Drug Take-Back Day events. For the event that happened nationwide on September 26, 2015, more than 130 CVS Pharmacy locations acted as a host site for these events. We have also created a Community Outreach Program that discusses the dangers of prescription drug abuse and the effects that one choice can have on individuals and their families. This presentation is geared toward high school students, and all pharmacists at CVS Pharmacy have the opportunity to present this program to their local high school and make a difference in the community. The comments contained herein are the opinion of CVS Caremark Medical Affairs. This document contains proprietary information of CVS Health and cannot be reproduced, distributed or printed without written permission from CVS Health. Saving projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. ©2016 CVS Health. All rights reserved. 106-36743A 022216 February 2016 Clinical Knowledge Management News for Clients Questions and Answers for Clients Have CVS Health programs been effective? Current programs are effective. For example, in 2014, total net pharmacy savings per member per month (PMPM) for the SMS program was $58, and total net pharmacy savings PMPM for the ESMS program was $136.b Total gross pharmacy savings in 2014 from SMS and ESMS combined was close to $80.1 million.b What is being considered for the future? We are continually reviewing current programs, determining areas for improvement and developing comprehensive strategies. Areas identified for improvement include program enhancements, coordinated member and physician education and more diverse treatment options. Opportunity exists to further reduce cost and create clinical outcome value for clients. Initiatives include the following: • Through enhanced reporting and communication, help support clients’ intervention efforts • Continue to help ensure programs are consistent with current pain management guidelines • Support access to and encourage use of medication-assisted treatment • Support overdose prevention and medication disposal initiatives • Develop a website for member, public and provider education • Continually refine identification of and intervention with high-risk patients and prescribers • Enhance program cost-saving documentation and reporting to clients Where is there further information or news about opioids? The CDC provides a number of publications and news on opioids at: http://www.cdc.gov/drugoverdose/pubs/index.html#tabs-760094-4. Both the American Pain Society website at http://ampainsoc.org and the American Academy of Pain Medicine website at http://www.painmed.org also feature current news about opioids. What does this mean for clients? Our controlled substance management programs help to ensure safe and more clinically appropriate controlled substance medication therapy for members and retail customers, and to produce cost savings for clients through more clinically appropriate medication regimens. We are continually improving our programs. Please contact your Clinical Advisor to discuss the different controlled substance management programs that would best align with your pharmacy benefit plan. b Total pharmacy savings are calculated by subtracting the pharmacy costs following program intervention from the pharmacy costs prior to program intervention. The comments contained herein are the opinion of CVS Caremark Medical Affairs. This document contains proprietary information of CVS Health and cannot be reproduced, distributed or printed without written permission from CVS Health. Saving projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. ©2016 CVS Health. All rights reserved. 106-36743A 022216 February 2016 Clinical Knowledge Management News for Clients References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2)(PMC4043401):113-130. U.S. Food and Drug Administration. Controlled Substances Act. Title 21 Food and Drugs, Chapter 13 Drug Abuse Prevention and Control, Subchapter I Control and Enforcement. Last updated June 11, 2009. http://www.fda.gov/regulatoryinformation/legislation/ucm148726.htm. Accessed November 13, 2015. Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Washington, D.C.: U.S. Department of Health and Human Services; 2013. http://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf. Accessed November 12, 2015. Centers for Disease Control and Prevention (CDC). Vital Signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492. Opioid abuse in the U.S. and HHS actions to address opioid-drug related overdoses and deaths. ASPE Issue Brief. U.S. Department of Health and Human Services website. http://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths. March 26, 2015. Accessed November 11, 2015. Drug scheduling. Drug Enforcement Administration website. http://www.dea.gov/druginfo/ds.shtml. Accessed November 11, 2015. What is prescription drug abuse? National Institute on Drug Abuse website. http://www.drugabuse.gov/publications/research-reports/prescription-drugs/whatprescription-drug-abuse. Accessed November 16, 2015. Paulozzi LJ, Strickler GK, Kreiner PW, Koris CM. Controlled substance prescribing patterns—prescription behavior surveillance system, eight states, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(9):1-14. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6409a1.htm?s_cid=ss6409a1_e. Accessed November 11, 2015. 2015 National Drug Threat Assessment Summary. Drug Enforcement Administration; 2015. http://www.dea.gov/docs/2015%20NDTA%20Report.pdf. Accessed November 13, 2015. Frenk SM, Porter KS, Paulozzi LJ. Prescription opioid analgesic use among adults: United States, 1999-2012. NCHS data brief, no 189. Hyattsville, MD: National Center for Health Statistics; 2015. http://www.cdc.gov/nchs/data/dataBriefs/db189.pdf. Accessed October 14, 2015. Buprenorphine. Drugs.com website. http://www.drugs.com/mtm/buprenorphine.html. Accessed December 9, 2015. Methadone. Drugs.com website. http://www.drugs.com/methadone.html. Accessed December 9, 2015. What are opioids? National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/research-reports/prescription-drugs/opioids/what-areopioids. Accessed October 15, 2015. Pain Management Opioid Safety: VA Educational Guide (2014). U.S.Department of Veterans Affairs; 2014. http://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Guide_7_17.pdf. Accessed October 16, 2015. Han B, Compton WM, Jones CM, Cai R. Nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the United States, 2003-2013. JAMA. 2015;314(14):1468-1478. VA National Pain Management Program. Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain. U.S. Department of Veterans Affairs. http://www.va.gov/PAINMANAGEMENT/docs/TakingOpioidsResponsibly20121017.pdf. Accessed October 16, 2015. Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, Roland CL. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Med. 2011;12(4):657-667. Hansen RN, Oster G, Edelsberg J, Woody GE, Sullivan SD. Economic costs of nonmedical use of prescription opioids. Clin J Pain. 2011;27(3):194-202. Rice JB, Kirson NY, Shei A, et al. Estimating the costs of opioid abuse and dependence from an employer perspective: a retrospective analysis using administrative claims data. Appl Health Econ Health Policy. 2014;12(4)(PMC4287687):435-446. New CDC opioid prescribing guidelines: improving the way opioids are prescribed for safer chronic pain treatment. Centers for Disease Control and Prevention website. http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed October 16, 2015. Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010;13(5):401-435. Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Accessed November 12, 2015. King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: a systematic review. Am J Public Health. 2014;104(8)(PMC4103240):e32-e42. Martin BC, Fan MY, Edlund MJ, DeVries A, Braden JB, Sullivan MD. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011;26(12)(PMC3235603):1450-1457. Interagency Guideline on Prescribing Opioids for Pain. Developed by the Washington State Agency Medical Directors' Group (AMDG) in collaboration with an Expert Advisory Panel, Actively Practicing Providers, Public Stakeholders, and Senior State Officials. 3rd ed. Washington State Agency Medical Directors' Group; June 2015. http://www.agencymeddirectors.wa.gov. Accessed November 24, 2015. Schneider C, Yale SH, Larson M. Principles of pain management. Clin Med Res. 2003;1(4)(PMC1069064):337-340. National Center for Injury Prevention and Control. Common elements in guidelines for prescribing opioids for chronic pain. Centers for Disease Control and Prevention website. http://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-a.pdf. Accessed September 4, 2015. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic noncancer pain: Part 2—guidance. Pain Physician. 2012;15(3 Suppl):S67-S116. URAC. Pharmacy benefit management: accreditation as a new quality yardstick. Issue Brief. Februrary 2008. http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=12076. Accessed October 19, 2015. The comments contained herein are the opinion of CVS Caremark Medical Affairs. This document contains proprietary information of CVS Health and cannot be reproduced, distributed or printed without written permission from CVS Health. Saving projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Client-specific modeling available upon request. CVS Caremark does not operate the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. ©2016 CVS Health. All rights reserved. 106-36743A 022216