Opioid Action Council

Part 1 - February 2018

Effective August 31, 2017, the State of Ohio issued new rules for prescribing opioid analgesics for the treatment of acute pain. The issued limits in the rules DO NOT apply to the use of opioids for the treatment of chronic pain. For a complete list of these rules, please visit Ohio’s Board of Pharmacy website.

Starting December 29, 2017, rule 4729-5-30 will also see two new changes. Prescribers will be required to include the diagnosis code (ICD-10) or the full procedure code on all opioid prescriptions. The rule also requires providers to indicate the days’ supply on all controlled substance and gabapentin prescriptions.

The State of Ohio issued guidelines for prescribing opioids for the treatment of chronic, non-terminal pain, which can be viewed in full here (PDF). To assist in calculating a patient’s morphine equivalent dose, please use the following conversion table (PDF) provided by the Board of Pharmacy.

Part 2 - March 2018

In order to assist providers with the new prescribing limits, ODM (Ohio Department of Medicaid), in conjunction with all five Medicaid Managed Care Plans, developed opioid prescribing limits and clinical prior authorization policies for Medicaid members. Below is a link for information on accessing the Ohio Automated Rx Reporting System (OARRS) and the usage laws. In our next newsletter, we will discuss what has been done in the state of Ohio in 2017 to address the opioid crisis.

In order to view the new opioid prescribing limits and clinical prior authorization policies, please click on the link below:

New Opioid Limits and Clinical Prior Authorization Policy

The OARRS is a web-based system that collects information on all outpatient prescriptions for controlled substances that are dispensed by Ohio licensed pharmacies and prescribed or personally furnished by licensed prescribers in Ohio. Ohio law requires that each prescriber who prescribes opioid analgesics or benzodiazepines have a registered OARRS account. Please click on the link below for more information on how to register and what the Ohio laws around OARRS requests are.

Mandatory OARRS Registration and Requests - State of Ohio Board of Pharmacy

Part 3 - May 2018

** A quick reminder of law updates for the prescribing of controlled substances:

• As of December 29, 2017, rule 4729-5-30 requires prescribers to include the first four alphanumeric characters (ex. M16.5) of the diagnosis code (ICD-10) or the Code on Dental Procedures and Nomenclature (CDT Code) on all opioid analgesic prescriptions.
• This requirement will take effect for all other controlled substance prescriptions on June 1, 2018.

The majority of drug overdose deaths (66%) involve an opioid. Here are some quick stats involving opioid overdose:

• In 2016, the number of overdose deaths in the US involving opioids (including prescription opioids and heroin) was 5 times higher than in 1999.1
  Deaths from prescription opioids in the US – drugs like oxycodone, hydrocodone, and methadone – have more than quadrupled since 1999. 40% of all US opioid overdose deaths involve a prescribed opioid.1
• In 2011, Governor John R. Kasich announced the establishment of the Governor’s Cabinet Opiate Action Team to fight opiate abuse in Ohio. Ohio is combating drug abuse through many initiatives on several fronts at the state and local levels. Please click to see what has been done over the last few years by the state of Ohio (PDF).

On a positive note, the State of Ohio Board of Pharmacy reported in March 2018 that opioid prescribing in Ohio is down nearly 30% in 2017. Please click to read the report released from the State Board of Pharmacy (PDF).

While addiction and opioid treatment programs are currently in place at Buckeye Health Plan, our staff is continually working to develop new ideas to help combat the epidemic. Examples of our existing programs include:

• Coordinated Services Program (Lock in program)
  • Members who have multiple opioid prescriptions from multiple providers AND/OR more than 3 prescriptions for naloxone/Narcan/Vivitrol may be locked into one pharmacy of their choice for 2 years. These members are also referred to case management.
• Opioid overdose ED/Narcan Program
  • Pharmacists review reports of members who have an ED visit for any drug overdose or a prescription for Narcan and refer to case management if necessary.
• Pregnancy Start Smart Program
  • Maternal/newborn program that encourages and supports member education, prenatal care, and treatment plans. This program can help identify high risk pregnancies, such as addiction, and provide the proper education and treatment to members.

Part 4 - Changes Effective 7/1/2018

The following changes are being implemented in conjunction with the Ohio Department of Medicaid (ODM) and apply to all Medicaid managed care plans.  Please note that these changes only affect short-acting opioids prescribed for opioid naïve/acute members (defined as having less than a 1-day supply of opioids in the previous 90 days):

• Maximum of 30 MED (morphine equivalent dose) per prescription
• The maximum 7-day supply limit on prescriptions for opioid naïve/acute members will still be in place

The above new limits for opioid naïve/acute members do NOT replace the current short-acting opioid limits for sub-acute users (defined as those having less than 90 days of opioids in the last 120 days):

• Maximum of 60 MED (cumulative) per prescription
• Maximum 7-day supply allowed on short-acting opioid prescriptions
• Limit of 14 day supply per rolling 45 days will be removed

In addition, ODM and the Medicaid managed care plans will implement other changes, effective 7/1/2018, for members who are new to medication assisted therapy (MAT):

• First 7 day supply of prescription will not require a prior authorization    
• Medications used as part of MAT therapy are buprenorphine containing products prescribed for opioid dependence 

Part 5 - August 2018

The CDC has provided a guideline for prescribing opioids for chronic pain. It outlines how to determine when to initiate or continue opioids for chronic pain, opioid selection, dosage, duration, follow-up, and discontinuation, and assessing risk and addressing harms of opioid use.

Nearly 80 percent of individuals with an opioid use disorder do not receive treatment. The first barrier to accessing treatment is failure to recognize substance use disorder. It is imperative that today’s health care providers try to overcome this barrier

Symptoms of opioid use disorder include:

• Strong desire for opioids, inability to control or reduce use, continued use despite interference with major obligations or social functioning, use of larger amounts over time, development of tolerance, and spending a great deal of time to obtain and use opioids. In addition, withdrawal symptoms that occur after stopping or reducing use include negative mood, nausea or vomiting, muscle aches, diarrhea, fever, and insomnia.

Once a patient is identified as having an opioid use disorder, it is critical to provide the help and treatment they need. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a pocket guide for medication-assisted treatment of opioid use disorder which includes a checklist for assessing the need for treatment and other information on prescribing medications approved for treatment. The link to the guide also includes a clinical opiate withdrawal scale to aid in monitoring any withdrawal symptoms over time.