A Successful Multipronged Approach to Reduce Opioid Abuse
One year on, implementation of the Narcotic Safety Initiative is showing promising results in California.
Blue Shield of California, a nonprofit health plan with the mission “to ensure all Californians have access to high-quality health care at an affordable price,” is independent from the Blue Cross Blue Shield Association, a leading health insurance organization covering more than 106 million Americans. One way through which Blue Shield implements its mission is by providing grants to the California HealthCare Foundation (CHCF); in the past 10 years, Blue Shield has awarded more than $325 million to the Foundation.
In response to the opioid epidemic that has spread throughout the United States—with a quadrupling of opioid prescriptions in the past 15 years, leading to increased incidence of drug overdoses and addiction—Blue Shield of California launched the Narcotic Safety Initiative. Started in 2015, this 3-year program aims to help Blue Shield's plan participants curb the epidemic and seeks to “reduce inappropriate prescribing and overuse of opioid narcotic medications for [its] members by at least 50% by the end of 2018.”
Blue Shield of California's Chief Health Officer, Marcus Thygeson, MD, MPH, stated in a Blue Shield press release: "The focus of Blue Shield's program is twofold. We want to reduce unnecessary initial use of opioids for acute and chronic pain so that members are not unnecessarily exposed to the potential for chronic opioid dependence or addiction, and also promote safer opioid doses for those already on chronic opioid therapy." He added, "The opioid epidemic in the United States is a serious public health crisis, and we've made it a priority to work together with the rest of the healthcare delivery system to reduce opioid overuse."
An infographic by the CHCF clearly outlines their 4-part prescription health plan, which they believe “can influence the behavior of providers and patients, prevent overprescribing, ensure appropriate treatment is available—and save lives.”1
This plan advocates promotion of judicious prescribing practices through provider education and training, as well as availability of comparative data and performance-based financial incentives. A focus on improved member outcomes is also encouraged through education, improved care coordination, easing of access to buprenorphine, and coverage of non-opioid pain treatments.
In addition, the CHCF plan urges detection of overuse, misuse, and fraud through patient review; identification of outlier prescribers, pharmacies, and members; and promotion of prescription drug monitoring programs, such as the Controlled Substance Utilization Review and Evaluation System program (CURES).2 Finally, the plan aims to support safe communities by improving prescribing practices through promotion and distribution of naloxone and by upscaling participation in opioid safety coalitions.
On June 29, 2016, the CHCF released a white paper titled “Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic.”3 This publication was based on an online survey sent to 35 health plans throughout California (30 responses from 28 plans were collected) and reports on the numerous positive results yielded during the initial year of implementation of the Narcotic Safety Initiative.
Efforts highlighted in the white paper as having been the most successful include multifaceted approaches aiming to reduce opioid use. Highest-risk situations (eg, high-risk medication combinations) were targeted; safe communities were supported; and opioid misuse, overuse, and fraud were identified and addressed. Another successful measure featured the effective use of data, which can be leveraged to promote behavioral change in outlier prescribers or to demonstrate program effectiveness.
Responses to the online survey revealed that non-opioid treatments were offered by a vast majority of commercial (n=8) and Medi-Cal (n=17) plans (chiropractic services, 88% and 52%, respectively; acupuncture, 88% and 41%, respectively). Nearly three-quarters (71%) of all health plans surveyed were integrating primary care, mental health services, and addiction treatments, with an additional 11% considering such measures.
Regarding access to buprenorphine, all commercial plans surveyed reported providing the drug to treat opioid addiction; 50% also prescribed the drug for pain management. In addition, opioid safety coalitions are being established in local communities across the state, 16 of which are supported by the CHCF. These coalitions are led by organizations ranging from public health departments to medical societies and seek to promote sensible prescribing practices and increase the use of naloxone. Approximately 52% of survey responders belonged to such a coalition, with an additional 38% planning on joining one.
In terms of formulary and authorization policies, 60% of plans reported implementing dose limits on some opioids, with another 30% planning to do so. Education efforts and/or training were in place for most health plans surveyed, with 64% publishing practice guidelines, 43% providing educational programs (including continuing medical education programs), and 71% promoting the use of the CURES program. Pay-per-performance practices aiming to promote safe opioid prescribing were not widespread, however, with only 11% of health plans with such measures in place and 36% considering them.
The authors of the white paper concluded that “all health plans interviewed are working on the issue in some way, and many plans contacted for this report indicated that they are actively planning to expand their efforts.”
1. Health plan Rx for the opioid epidemic. California Healthcare Foundation. Available at:
2. The Controlled Substance Utilization Review and Evaluation System – California's prescription drug monitoring program. Available at: https://oag.ca.gov/cures. Accessed July 12, 2016.
3. Changing course: the role of health plans in curbing the opioid epidemic. California Healthcare Foundation. Available at: http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20ChangingHealthPlansOpioid.pdf. Accessed July 12, 2016.